CD001450

Cochrane Database of Systematic Reviews
Fetal and umbilical Doppler ultrasound in normal pregnancy

(Review)
Alfirevic Z, Stampalija T, Medley N
Alfirevic Z, Stampalija T, Medley N.

Fetal and umbilical Doppler ultrasound in normal pregnancy.
Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD001450.
DOI: 10.1002/14651858.CD001450.pub4.
www.cochranelibrary.com
Fetal and umbilical Doppler ultrasound in normal pregnancy (Review)

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . 3
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Analysis 1.1. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 1 Perinatal death
(stillbirth and neonatal death including anomalies). . . . . . . . . . . . . . . . . . . . . . 39
Analysis 1.2. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 2 Serious neonatal
morbidity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Analysis 1.3. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 3 Any death after
randomisation (non-prespecified). . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Analysis 1.4. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 4 Stillbirth. . 42
Analysis 1.5. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 5 Neonatal death (up
to 28 days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Analysis 1.6. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 6 Potentially
preventable perinatal death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Analysis 1.7. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 7 Fetal acidosis. 45
Analysis 1.8. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 8 Apgar score < 7 at 5
minutes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Analysis 1.9. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 9 Caesarean section
(elective and emergency). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Analysis 1.10. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 10 Elective caesarean
section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Analysis 1.11. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 11 Emergency
caesarean section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Analysis 1.12. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 12 Spontaneous
vaginal birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Analysis 1.13. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 13 Operative vaginal
birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Analysis 1.14. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 14 Induction of
labour. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Analysis 1.15. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 15 Neonatal
resuscitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Analysis 1.16. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 16 Infant
intubation/ventilation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Analysis 1.17. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 17 Preterm birth
(before 37 weeks). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Analysis 1.18. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 18 Neonatal
admission to SCBU/NICU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Analysis 1.19. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 19 Birthweight. 57
Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) i
Analysis 1.20. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 20 Gestational age
at birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Analysis 2.1. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 1 Perinatal
death (stillbirth and neonatal death including anomalies). . . . . . . . . . . . . . . . . . . . 59
Analysis 2.2. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 2 Stillbirth. 60
Analysis 2.3. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 3 Neonatal
death (up to 28 days after birth). . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Analysis 2.4. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 4 Any death
after randomisation (non-prespecified). . . . . . . . . . . . . . . . . . . . . . . . . . 62
Analysis 2.5. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 5 Potentially
Analysis 2.6. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 6 Apgar score
< 7 at 5 minutes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Analysis 2.7. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 7 Caesarean
section (elective and emergency). . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Analysis 2.8. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 8 Elective
Analysis 2.9. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 9 Emergency
Analysis 2.10. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 10
Spontaneous vaginal birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Analysis 2.11. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 11 Operative
vaginal birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Analysis 2.12. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 12 Induction
of labour. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Analysis 2.13. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 13 Neonatal
resuscitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Analysis 2.14. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 14 Preterm
birth (before 37 weeks). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Analysis 2.15. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 15
Birthweight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Analysis 2.16. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome 16 Gestational
age at birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Analysis 3.1. Comparison 3 Multiple Doppler ultrasound assessments versus no Doppler ultrasound, Outcome 1 Perinatal
death (stillbirth and neonatal death including anomalies). . . . . . . . . . . . . . . . . . . . 75
Analysis 3.2. Comparison 3 Multiple Doppler ultrasound assessments versus no Doppler ultrasound, Outcome 2 Serious
neonatal morbidity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Analysis 3.3. Comparison 3 Multiple Doppler ultrasound assessments versus no Doppler ultrasound, Outcome 3 Any death
after randomisation (non-prespecified). . . . . . . . . . . . . . . . . . . . . . . . . . 77
Analysis 3.4. Comparison 3 Multiple Doppler ultrasound assessments versus no Doppler ultrasound, Outcome 4
Stillbirth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Analysis 3.5. Comparison 3 Multiple Doppler ultrasound assessments versus no Doppler ultrasound, Outcome 5 Neonatal
death (up to 28 days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Analysis 3.6. Comparison 3 Multiple Doppler ultrasound assessments versus no Doppler ultrasound, Outcome 6 Potentially
Analysis 3.7. Comparison 3 Multiple Doppler ultrasound assessments versus no Doppler ultrasound, Outcome 7 Apgar
score < 7 at 5 minutes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Analysis 3.8. Comparison 3 Multiple Doppler ultrasound assessments versus no Doppler ultrasound, Outcome 8 Caesarean
section (elective and emergency). . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Analysis 3.9. Comparison 3 Multiple Doppler ultrasound assessments versus no Doppler ultrasound, Outcome 9 Elective
Emergency caesarean section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) ii
Spontaneous vaginal birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Induction of labour. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Neonatal resuscitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Analysis 3.14. Comparison 3 Multiple Doppler ultrasound assessments versus no Doppler ultrasound, Outcome 14 Preterm
birth (before 37 weeks). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Neonatal admission to SCBU/NICU. . . . . . . . . . . . . . . . . . . . . . . . . . 89
Birthweight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Gestational age at birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 93
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) iii

[Intervention Review]
Fetal and umbilical Doppler ultrasound in normal pregnancy
Zarko Alfirevic1 , Tamara Stampalija2 , Nancy Medley3

1 Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK. 2 Unit of Prenatal Diagnosis, Institute
for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy. 3 Cochrane Pregnancy and Childbirth Group, Department of
Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
Contact address: Zarko Alfirevic, Department of Women’s and Children’s Health, The University of Liverpool, First Floor, Liverpool
Women’s NHS Foundation Trust, Crown Street, Liverpool, L8 7SS, UK. zarko@liverpool.ac.uk.
Editorial group: Cochrane Pregnancy and Childbirth Group.

Publication status and date: Edited (no change to conclusions), published in Issue 6, 2015.
Citation: Alfirevic Z, Stampalija T, Medley N. Fetal and umbilical Doppler ultrasound in normal pregnancy. Cochrane Database of
Systematic Reviews 2015, Issue 4. Art. No.: CD001450. DOI: 10.1002/14651858.CD001450.pub4.
ABSTRACT
Background
One of the main aims of routine antenatal care is to identify the ’at risk’ fetus in order to apply clinical interventions which could
result in reduced perinatal morbidity and mortality. Doppler ultrasound study of umbilical artery waveforms helps to identify the
compromised fetus in ’high-risk’ pregnancies and, therefore, deserves assessment as a screening test in ’low-risk’ pregnancies.
Objectives
To assess the effects on obstetric practice and pregnancy outcome of routine fetal and umbilical Doppler ultrasound in unselected and
low-risk pregnancies.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group Trials Register (28 February 2015) and reference lists of retrieved studies.
Selection criteria
Randomised and quasi-randomised controlled trials of Doppler ultrasound for the investigation of umbilical and fetal vessels waveforms
in unselected pregnancies compared with no Doppler ultrasound. Studies where uterine vessels have been assessed together with fetal
and umbilical vessels have been included.
Data collection and analysis
Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. In addition
to standard meta-analysis, the two primary outcomes and five of the secondary outcomes were assessed using GRADE software and
methodology.
Main results
We included five trials that recruited 14,624 women, with data analysed for 14,185 women. All trials had adequate allocation conceal-
ment, but none had adequate blinding of participants, staff or outcome assessors. Overall and apart from lack of blinding, the risk of
bias for the included trials was considered to be low.
Overall, routine fetal and umbilical Doppler ultrasound examination in low-risk or unselected populations did not result in increased
antenatal, obstetric and neonatal interventions. There were no group differences noted for the review’s primary outcomes of perinatal
Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 1
death and neonatal morbidity. Results for perinatal death were as follows: (average risk ratio (RR) 0.80, 95% confidence interval (CI)
0.35 to 1.83; four studies, 11,183 participants). Only one included trial assessed serious neonatal morbidity and found no evidence of
group differences (RR 0.99, 95% CI 0.06 to 15.75; one study, 2016 participants).
For the comparison of a single Doppler assessment versus no Doppler, evidence for group differences in perinatal death was detected (RR
0.36, 95% CI 0.13 to 0.99; one study, 3891 participants). However, these results are based on a single trial, and we would recommend
caution when interpreting this finding.
There was no evidence of group differences for the outcomes of caesarean section, neonatal intensive care admissions or preterm birth
less than 37 weeks.
When the quality of the evidence for the main comparison of ’All Doppler versus no Doppler’ was assessed with GRADE software, the
outcomes of perinatal death and serious neonatal morbidity data were graded as of low quality. Evidence for the outcome of stillbirth
was graded according to regimen subgroups - with a moderate quality rating for stillbirth (fetal/umbilical vessels only) and a low quality
rating for stillbirth (fetal/umbilical vessels + uterine artery vessels). Evidence for admission to neonatal intensive care unit was assessed
as of moderate quality, and evidence for the outcomes of caesarean section and preterm birth less than 37 weeks was graded as of high
quality.
There is no available evidence to assess the effect on substantive long-term outcomes such as childhood neurodevelopment and no data
to assess maternal outcomes, particularly maternal satisfaction.
Authors’ conclusions
Existing evidence does not provide conclusive evidence that the use of routine umbilical artery Doppler ultrasound, or combination of
umbilical and uterine artery Doppler ultrasound in low-risk or unselected populations benefits either mother or baby. Future studies
should be designed to address small changes in perinatal outcome, and should focus on potentially preventable deaths.
PLAIN LANGUAGE SUMMARY

Doppler ultrasound of fetal blood vessels in normal pregnancies
One of the main aims of routine antenatal care is to identify babies who are not thriving in the womb. It is possible that medical
interventions might improve outcomes for these babies, if they can be identified. Doppler ultrasound uses sound waves to detect the
movement of blood in vessels. It is used in pregnancy to study blood circulation in the baby, uterus and placenta. Using it in high-risk
pregnancies, where there is concern about the baby’s condition, shows benefits. However, its value as a screening tool in all pregnancies
needs to be assessed as there is a possibility of unnecessary interventions and adverse effects. The review of trials of routine Doppler
ultrasound of the baby’s vessels in pregnancy identified five studies involving more than 14,000 women and babies. The studies were
not of high quality and were all undertaken in the 1990s. There were no improvements identified for either the baby or the mother,
though more data would be needed to prove whether it is effective or not for improving outcomes.

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]
All routine Doppler ultrasound versus no Doppler ultrasound
Patient or population: Pregnant wom en in unselected or low-risk populations.

Settings: Trials took place in Australia, France and the UK.
Intervention: All routine Doppler ultrasound versus no Doppler ultrasound
Outcomes Illustrative comparative risks* (95% CI) Relative effect No of Participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk
No Doppler ultrasound All routine Doppler ul-

trasound
Perinatal death (still- Study population RR 0.8 11183 ⊕⊕

birth and neona- (0.35 to 1.83) (4 studies) low1,2
tal death including 9 per 1000 7 per 1000
anomalies) (3 to 16)
M oderate
7 per 1000 6 per 1000

(2 to 13)
Serious neonatal mor- Study population RR 0.99 2016 ⊕⊕

bidity (0.06 to 15.75) (1 study) low3
1 per 1000 1 per 1000
(0 to 16)
M oderate
1 per 1000 1 per 1000

(0 to 16)
3
Stillbirth - Fetal/ umbil- Study population RR 0.34 6877 ⊕⊕⊕ Evlidence f or the still-
ical vessels only (0.12 to 0.95) (2 studies) moderate 4 birth outcom e has been
4 per 1000 1 per 1000 graded separately ac-
(0 to 4) cording to subgroup
M oderate
4 per 1000 1 per 1000

(0 to 4)
Stillbirth - Fetal/ umbil- Study population RR 1.41 5276 ⊕⊕

ical vessels + uterine (0.44 to 4.46) (2 studies) low2,5
artery 6 per 1000 9 per 1000
(3 to 27)
M oderate
6 per 1000 8 per 1000

(3 to 27)
Cae- Study population RR 0.98 6373 ⊕⊕⊕⊕

sarean section (elec- (0.85 to 1.13) (2 studies) high
tive and emergency) 108 per 1000 106 per 1000
(92 to 122)
M oderate
102 per 1000 100 per 1000

(87 to 115)
Preterm birth (before Study population RR 1.02 12162 ⊕⊕⊕⊕

37 weeks) (0.86 to 1.21) (4 studies) high
51 per 1000 52 per 1000
(44 to 62)
M oderate
4
47 per 1000 48 per 1000

(40 to 57)
Neonatal admission to Study population RR 0.99 7477 ⊕⊕⊕

special care baby unit/ (0.84 to 1.17) (3 studies) moderate 4
neonatal intensive care 66 per 1000 65 per 1000
unit (55 to 77)
M oderate
35 per 1000 35 per 1000

(29 to 41)
* The basis f or the assumed risk (e.g. the m edian control group risk across studies) is provided in f ootnotes. The corresponding risk (and its 95% conf idence interval) is
based on the assum ed risk in the com parison group and the relative effect of the intervention (and its 95% CI).
CI: Conf idence interval; RR: Risk ratio;
GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 Statistical heterogeneity (I 2 = 67%).
2
Wide conf idence interval crossing the line of no ef f ect.
3
Few events and wide conf idence interval crossing the line of no ef f ect (-2).
4 M ost of the pooled ef f ect f rom a study with design lim itations - specif ically problem s with random isation.
5 Statistical heterogeneity (I 2 = 63%).
5
BACKGROUND Flow of the umbilical and fetal arteries is most often quantified
either by pulsatility index or resistant index (Burns 1993; Nelson
1988). These indices reflect the down stream vascular resistance by
quantifying the differences between the peak systolic and the end-
Description of the condition diastolic velocity within blood vessels of interest in each cardiac
cycle. A high ratio in umbilical artery indicates a high vascular
One of the main aims of routine antenatal care is to identify the ’at
impedance and possible feto-placental compromise. In extreme
risk’ fetus in order to apply clinical interventions which could result
circumstance the blood flow at the end of diastole may be absent
in reduced perinatal morbidity and mortality (RCOG 1997). The
or even reversed.
routine use of a screening test should be based on proven clinical
Initial Doppler studies have been restricted to the umbilical artery,
effectiveness, to avoid subjecting a large group of normal women
but other fetal vessels have recently become a focus of interest
to anxiety and inappropriate intervention with subsequent risk of
including middle cerebral artery and ductus venosus.
iatrogenic morbidity and mortality.
In the majority of cases fetal death can be attributed to a
’known’ cause such as maternal disorder (hypertension, diabetes
and others), fetal pathology (congenital abnormalities, intrauter- How the intervention might work
ine growth restriction (IUGR)), placental pathologies or intra- Although stillbirths and fetal complications related to placental
partum complications. The rate of unexplained fetal deaths de- problems are rare in uncomplicated pregnancy, the impact is devas-
creased from 3.5 per 1000 total births in the1960s to 1.1 to 1.9 tating. Current methods for the assessment of fetal well-being and
per 1000 in the 1990s (Chibber 2005; Fretts 1992; Huang 2000). detection of compromised fetus in the routine antenatal care in-
Unrecognised IUGR remains the main cause of unexplained still- clude: symphysis fundal height measurement from the 24th week
births in otherwise uncomplicated pregnancies. Two recent stud- (Neilson 1998a; NICE 2008), fetal movements charts (Mangesi
ies identified fetal growth restriction in 43% (Gardosi 2005) and 2007) and antenatal cardiotocography (Pattison 1999). None of
52% (Froen 2004) of unexplained stillbirths, respectively, con- them, however, have proven ability to make an impact on perinatal
cluding that IUGR was the strongest risk factor for an unexplained mortality and morbidity.
intrauterine death. Observational and longitudinal studies of Doppler ultrasound in
It is important to highlight that fetal growth restriction is often unselected or low-risk pregnancies have raised doubts about its
confused with the concept of being small-for-gestational age. Some efficacy and authors have cautioned against its introduction into
fetuses are constitutionally small and they do not have increased obstetric practice without supportive evidence from randomised
perinatal mortality or morbidity. Inability to distinguish easily be- trials (Beattie 1989; Goffinet 1997; Sijoms 1989). The relatively
tween small but healthy fetuses and those who are failing to reach low incidence of preventable adverse perinatal outcomes in low-
their growth potential has hampered attempts to find appropri- risk and unselected populations present a challenge in evaluating
ate treatment for growth restriction (Soothill 1993). Growth-re- the clinical effectiveness of routine Doppler ultrasound, as large
stricted fetuses are at increased risk of mortality and morbidity numbers are required to provide definitive evidence.
(Bernstein 2000; Fisk 2001). The serious morbidity includes in-
traventricular haemorrhage, bronchopulmonary dysplasia, necro-
tising enterocolitis, infection, pulmonary haemorrhage, hypother-
mia and hypoglycaemia (Fisk 2001). Early antenatal detection, Why it is important to do this review
treatment where appropriate, and timely delivery could minimise Any screening test has not only potential for benefit, but also
the risks significantly. for harm (Barnett 1995). Subjecting a large group of low-risk
patients to a screening test with a relatively high false positive rate
is likely to cause anxiety and lead to inappropriate intervention
and subsequent risk of iatrogenic morbidity and mortality.
Description of the intervention Although epidemiological studies and a Cochrane review have
Doppler ultrasound technology is based on the Doppler shift, a found no correlation between the use of fetal Doppler ultra-
physical principle of the change of ultrasound frequency when sound and adverse neurological outcome in childhood develop-
aimed at the moving object (e.g. red blood cell) (Campbell 1983; ment, childhood malignancies and birth weight (Neilson 1998b;
Fitzgerald 1977; Nelson 1988; Owen 2001). Different Doppler Salvesen 2007), some concern about the association between the
methods are used in obstetrics: continuous-wave, pulsed-wave, left-handedness in males and exposure to Doppler ultrasound has
colour and power Doppler flow (Eik-Nes 1980; Mires 2000). been expressed (Kieler 2001; Kieler 2002; Salvesen 1999).
Doppler ultrasound examination can be performed as a part of a Considering that no recent studies have been done regarding the
more detailed ultrasound assessment that includes fetal biometry fetal exposure to Doppler ultrasound and the fact that the acous-
and anatomical survey, or as a separate ultrasound examination. tic output of a modern equipment has increased (Barnett 2001;

Duck 1991; Henderson 1997) indicates that Doppler ultrasound Types of interventions
in obstetrics should be used only if of proven value (in terms of Routine Doppler ultrasound of the fetal and umbilical artery cir-
improved outcome, good specificity and sensitivity). culation in pregnancy in unselected or low-risk populations. We
The continuous assessment of the evidence to provide the bal- included studies that considered the combination of utero-placen-
anced view of effectiveness, safety and cost-effectiveness is, there- tal Doppler and fetal or umbilical Doppler in normal pregnancies
fore, essential. In this review, we will focus on fetal and umbil- in this review.
ical Doppler ultrasound in low-risk and unselected pregnancies. If appropriate, we performed stratified analyses of all outcome
There are other reviews on ’Fetal and umbilical Doppler ultrasound measures in the following comparisons:
in high-risk pregnancies’ (Alfirevic 2013) and on ’Utero-placental 1. all routine Doppler versus no Doppler/concealed Doppler
Doppler ultrasound for improving pregnancy outcome’ (Stampalija examinations (i.e. caregivers not aware of results);
2010). 2. single Doppler measurement versus no Doppler/concealed
Doppler examinations;
3. multiple Doppler measurement versus no Doppler/
concealed Doppler examinations.
OBJECTIVES
Types of outcome measures
To assess the effects of routine fetal and umbilical Doppler ultra-
We selected outcome measures with the help of a proposed core
sound, or a combination of uterine Doppler ultrasound and um-
data set of outcome measures (Devane 2007).
bilical Doppler ultrasound, in unselected and low-risk pregnancies
on obstetric practice and pregnancy.
Primary outcomes
A low-risk population is defined as a population where those con-
sidered at risk have been excluded. Criteria of ’at risk’ are defined 1. Perinatal death (stillbirths and neonatal deaths including
variably and this is taken into consideration. anomalies)
2. Serious neonatal morbidity - composite outcome including
In the context of this review ’unselected’ pregnant population hypoxic ischaemic encephalopathy, intraventricular
refers to a mixture of pregnant women with no identified risk fac- haemorrhage, bronchopulmonary dysplasia, necrotising
tors and those who may have some risk factors but the trialists enterocolitis
have not reported them separately.
Secondary outcomes
1. Stillbirth (as defined by trialists)
METHODS 2. Neonatal death (all neonatal deaths up to 28 days after
birth)
3. Any death after randomisation (all losses or deaths after
Criteria for considering studies for this review randomisation, including miscarriage) (non-prespecified
outcome)
4. Any potentially preventable perinatal death after
randomisation (from 24 weeks and excluding congenital
Types of studies
malformations, chromosomal abnormalities and termination of
All randomised controlled trials of routine fetal and umbilical pregnancy)
Doppler ultrasound, or a combination of uterine Doppler ultra- 5. Fetal acidosis
sound and umbilical Doppler ultrasound, in unselected or low-risk 6. Apgar score less than seven at five minutes
pregnancies. We included quasi-randomised trials, but planned to 7. Caesarean section (both elective and emergency)
undertake sensitivity analysis by trial quality. Had we identified 8. Elective caesarean section
studies that were published as conference abstracts only, we would 9. Emergency caesarean section
have tried to contact the authors for further details. We would have 10. Spontaneous vaginal birth
included them but undertaken sensitivity analyses of trial quality 11. Operative vaginal birth
(see Sensitivity analysis). 12. Induction of labour
13. Neonatal resuscitation required
14. Infant requiring intubation/ventilation
Types of participants 15. Neonatal fitting/seizures
Pregnant women in both unselected and low-risk populations. 16. Preterm birth (before 37 completed weeks of pregnancy)

17. Infant respiratory distress syndrome Data collection and analysis
18. Meconium aspiration
For the methods used when assessing the trials identified in the
19. Neonatal admission to special care or intensive care unit, or
previous version of this review, see Alfirevic 2010.
both
For this update, we used the following methods when assessing
20. Infant birthweight
the reports identified by the updated search.
21. Gestational age at birth
22. Length of infant hospital stay
23. Long-term infant/child neurodevelopmental outcome Selection of studies
24. Women’s views of care/satisfaction Two review authors independently assessed for inclusion all the
We have reported non-prespecified outcomes if we consider them potential studies identified as a result of the search strategy. We
to be important. resolved any disagreement through discussion or, if required, we
consulted the third review author.
We planned to create a Study flow diagram to map out the number
of records identified, included and excluded.
Search methods for identification of studies
The following methods section of this review is based on a standard
Data extraction and management
template used by the Cochrane Pregnancy and Childbirth Group.
We designed a form to extract data. For eligible studies, two re-
view authors extracted the data using the agreed form. We resolved
Electronic searches discrepancies through discussion or, if required, we consulted the
third review author. Data were entered into Review Manager soft-
We searched the Cochrane Pregnancy and Childbirth Group’s ware (RevMan 2014) and checked for accuracy.
Trials Register by contacting the Trials Search Co-ordinator (28 When information regarding any of the above was unclear, we
February 2015). planned to contact authors of the original reports to provide fur-
The Cochrane Pregnancy and Childbirth Group’s Trials Register ther details.
is maintained by the Trials Search Co-ordinator and contains trials
identified from:
1. monthly searches of the Cochrane Central Register of Assessment of risk of bias in included studies
Controlled Trials (CENTRAL); Two review authors independently assessed risk of bias for each
2. weekly searches of MEDLINE (Ovid); study using the criteria outlined in the Cochrane Handbook for Sys-
3. weekly searches of Embase (Ovid); tematic Reviews of Interventions (Higgins 2011). Any disagreement
4. monthly searches of CINAHL (EBSCO); was resolved by discussion or by involving a third assessor.
5. handsearches of 30 journals and the proceedings of major
conferences;
(1) Random sequence generation (checking for possible
6. weekly current awareness alerts for a further 44 journals
selection bias)
plus monthly BioMed Central email alerts.
Details of the search strategies for CENTRAL, MEDLINE, Em- We described for each included study the method used to generate
base and CINAHL, the list of handsearched journals and confer- the allocation sequence in sufficient detail to allow an assessment
ence proceedings, and the list of journals reviewed via the current of whether it should produce comparable groups.
awareness service can be found in the ‘Specialized Register’ section We assessed the method as:
within the editorial information about the Cochrane Pregnancy • low risk of bias (any truly random process, e.g. random
and Childbirth Group. number table; computer random number generator);
Trials identified through the searching activities described above • high risk of bias (any non-random process, e.g. odd or even
are each assigned to a review topic (or topics). The Trials Search date of birth; hospital or clinic record number);
Co-ordinator searches the register for each review using the topic • unclear risk of bias.
list rather than keywords.
(2) Allocation concealment (checking for possible selection
bias)
Searching other resources
We described for each included study the method used to con-
We looked for additional studies in the reference lists of the studies ceal allocation to interventions prior to assignment and assessed
identified. whether intervention allocation could have been foreseen in ad-
We did not apply any language or date restrictions. vance of, or during recruitment, or changed after assignment.

We assessed the methods as: (5) Selective reporting (checking for reporting bias)
• low risk of bias (e.g. telephone or central randomisation; We described for each included study how we investigated the
consecutively numbered sealed opaque envelopes); possibility of selective outcome reporting bias and what we found.
• high risk of bias (open random allocation; unsealed or non- We assessed the methods as:
opaque envelopes, alternation; date of birth); • low risk of bias (where it is clear that all of the study’s
• unclear risk of bias. prespecified outcomes and all expected outcomes of interest to
the review have been reported);
• high risk of bias (where not all the study’s prespecified
(3.1) Blinding of participants and personnel (checking for
outcomes have been reported; one or more reported primary
possible performance bias)
outcomes were not prespecified; outcomes of interest are
We described for each included study the methods used, if any, to reported incompletely and so cannot be used; study fails to
blind study participants and personnel from knowledge of which include results of a key outcome that would have been expected
intervention a participant received. We considered that studies to have been reported);
were at low risk of bias if they were blinded, or if we judged that • unclear risk of bias.
the lack of blinding unlikely to affect results. We assessed blinding
separately for different outcomes or classes of outcomes.
We assessed the methods as: (6) Other bias (checking for bias due to problems not
• low, high or unclear risk of bias for participants; covered by (1) to (5) above)
• low, high or unclear risk of bias for personnel. We described for each included study any important concerns we
had about other possible sources of bias.
(3.2) Blinding of outcome assessment (checking for possible

detection bias) (7) Overall risk of bias [See table 8.5c in the Handbook]
We described for each included study the methods used, if any, to We made explicit judgements about whether studies were at high
blind outcome assessors from knowledge of which intervention a risk of bias, according to the criteria given in the Handbook (
participant received. We assessed blinding separately for different Higgins 2011). With reference to (1) to (6) above, we planned to
outcomes or classes of outcomes. assess the likely magnitude and direction of the bias and whether
We assessed methods used to blind outcome assessment as: we considered it is likely to impact on the findings. In future
• low, high or unclear risk of bias. updates, we will explore the impact of the level of bias through
undertaking sensitivity analyses - see Sensitivity analysis.
For this update the quality of the evidence was assessed using
(4) Incomplete outcome data (checking for possible attrition
the GRADE approach (Schunemann 2009). The following key
bias due to the amount, nature and handling of incomplete outcomes for the comparison of ’all routine Doppler ultrasound
outcome data)
versus no Doppler ultrasound’ were assessed.
We described for each included study, and for each outcome or 1. Perinatal death (stillbirths and neonatal deaths including
class of outcomes, the completeness of data including attrition and anomalies)
exclusions from the analysis. We stated whether attrition and ex- 2. Serious neonatal morbidity
clusions were reported and the numbers included in the analysis at 3. Stillbirth - fetal/umbilical vessels subgroup
each stage (compared with the total randomised participants), rea- 4. Stillbirth - fetal/umbilical vessels + uterine artery
sons for attrition or exclusion where reported, and whether miss- 5. Caesarean section (elective and emergency)
ing data were balanced across groups or were related to outcomes. 6. Preterm birth < 37 weeks
Where sufficient information was reported, or could be supplied 7. Neonatal admission to Special care baby unit/neonatal
by the trial authors, we planned to re-include missing data in the intensive care unit
analyses which we undertook. GRADEprofiler (GRADE 2014) was used to import data from
We assessed methods as: Review Manager 5.3 (RevMan 2014) in order to create a ’Sum-
• low risk of bias (e.g. no missing outcome data; missing mary of findings’ table. A summary of the intervention effect and
outcome data balanced across groups); a measure of quality for each of the above outcomes was produced
• high risk of bias (e.g. numbers or reasons for missing data using the GRADE approach. The GRADE approach uses five con-
imbalanced across groups; ‘as treated’ analysis done with siderations (study limitations, consistency of effect, imprecision,
substantial departure of intervention received from that assigned indirectness and publication bias) to assess the quality of the body
at randomisation); of evidence for each outcome. The evidence can be downgraded
• unclear risk of bias. from ’high quality’ by one level for serious (or by two levels for very

serious) limitations, depending on assessments for risk of bias, in- Dealing with missing data
directness of evidence, serious inconsistency, imprecision of effect For included studies, we noted levels of attrition. In future updates,
estimates or potential publication bias. if more eligible studies are included, we will explore the impact
of including studies with high levels of missing data in the overall
Measures of treatment effect assessment of treatment effect by using sensitivity analysis.
For all outcomes, analyses were carried out, as far as possible, on an
intention-to-treat basis, that is, we attempted to include all partici-
Dichotomous data pants randomised to each group in the analyses. The denominator
for each outcome in each trial was the number randomised minus
For dichotomous data, we presented results as summary risk ratio
any participants whose outcomes were known to be missing.
with 95% confidence intervals.
Assessment of heterogeneity
Continuous data
We assessed statistical heterogeneity in each meta-analysis using
For continuous data, we used the mean difference if outcomes had the Tau², I² and Chi² statistics. We regarded heterogeneity as sub-
been measured in the same way between trials. We planned to use stantial if the I² was greater than 30% and either Tau² was greater
the standardised mean difference to combine trials that measure than zero, or there was a low P value (less than 0.10) in the Chi²
the same outcome, but used different methods. test for heterogeneity. We explored all outcomes by prespecified
subgroups (see below).
Unit of analysis issues
Assessment of reporting biases
Cluster-randomised trials In future updates, if there are 10 or more studies in the meta-
analysis, we will investigate reporting biases (such as publication
For this update, we have not included any cluster-randomised tri- bias) using funnel plots. We will assess funnel plot asymmetry
als. If in future updates we identify eligible cluster-randomised visually. If asymmetry is suggested by a visual assessment, we will
trials, we will include these in the analyses along with individu- perform exploratory analyses to investigate it.
ally-randomised trials. We will adjust their sample sizes using the
methods described in the Handbook [Section 16.3.4 or 16.3.6]
using an estimate of the intracluster correlation co-efficient (ICC) Data synthesis
derived from the trial (if possible), from a similar trial or from a We carried out statistical analysis using the Review Manager soft-
study of a similar population. If we use ICCs from other sources, ware (RevMan 2014). We used fixed-effect meta-analysis for com-
we will report this and conduct sensitivity analyses to investigate bining data where it was reasonable to assume that studies were
the effect of variation in the ICC. If we identify both cluster- estimating the same underlying treatment effect: i.e. where trials
randomised trials and individually-randomised trials, we plan to were examining the same intervention, and the trials’ populations
synthesise the relevant information. We will consider it reasonable and methods were judged sufficiently similar.
to combine the results from both if there is little heterogeneity Where there was clinical heterogeneity sufficient to expect that the
between the study designs and the interaction between the effect underlying treatment effects differed between trials, or if substan-
of intervention and the choice of randomisation unit is considered tial statistical heterogeneity was detected, we used random-effects
to be unlikely. meta-analysis to produce an overall summary, if an average treat-
We will also acknowledge heterogeneity in the randomisation unit ment effect across trials was considered clinically meaningful. The
and perform a sensitivity analysis to investigate the effects of the random-effects summary was treated as the average range of possi-
randomisation unit. ble treatment effects and we discussed the clinical implications of
treatment effects differing between trials. If the average treatment
effect was not clinically meaningful, we did not combine trials.
Cross-over trials
Where we used random-effects analyses, the results were presented
This is not an appropriate design for this review question. as the average treatment effect with 95% confidence intervals, and
the estimates of Tau² and I².
Other unit of analysis issues
In studies including multiple pregnancies, because of non-inde- Subgroup analysis and investigation of heterogeneity
pendence, we would have used cluster-trial methods and consulted We analysed all outcomes by subgroups to explore the clinical dif-
a statistician to help with the analyses. ference between regimens of Doppler ultrasound. We considered

whether an overall summary was meaningful if substantial hetero- tables of Characteristics of included studies and Characteristics of
geneity was not evident. Where necessary, we used random-effects excluded studies.
analysis to produce the summary. An updated search on 28 February 2015 identified two further
We carried out the following subgroup analysis for all outcomes reports (Forward 2014; Stoch 2012). These studies were additional
in all three comparisons: reports for the already included Newnham 1993 and were added
1. Fetal/umbilical Doppler ultrasound only versus fetal/ to the references.
umbilical and uteroplacental Doppler ultrasound.
We assessed subgroup differences by interaction tests available
Included studies
within RevMan (RevMan 2014). We reported the results of sub-
group analyses quoting the I² statistic and P value, and the in- The five included studies were all undertaken in the 1990s. Three
teraction test I² value. Where we found evidence of substantial studies used fetal/umbilical vessels only (French Doppler 1997;
subgroup differences with a P value of < 0.10, we have reported Mason 1993; Whittle 1994). Two studies used both uterine vessels
subtotals only for the outcome in question. and umbilical vessels (Davies 1992; Newnham 1993). One study
looked at a single assessment at 28 to 34 weeks (French Doppler
1997), three studies looked at more than one assessment (Davies
Sensitivity analysis 1992; Mason 1993; Newnham 1993) and one study had a mixture
of some women receiving a single assessment and others more than
For this update, we did not perform any sensitivity analysis. In
one assessment (Whittle 1994).
future updates, we will perform sensitivity analysis on the primary
outcomes based on trial quality, separating high-quality trials from
trials of lower quality. ’High quality’ will, for the purposes of this Excluded studies
sensitivity analysis, be defined as a trial having adequate sequence We excluded five studies because they studied uterine Doppler ul-
generation and allocation concealment. trasound only and not fetal and umbilical Doppler or a combina-
tion of uterine plus fetal and umbilical Doppler (Ellwood 1997;
Goffinet 2001; Snaith 2006; Subtil 2000; Subtil 2003). These
studies will be assessed in a separate review on ’Utero-placental
Doppler ultrasound for improving pregnancy outcome’. We excluded
RESULTS
two studies because the previous review authors had tried to con-
tact these authors for information needed for studies to be included
and had received no response (Gonsoulin 1991; Schneider 1992).
Description of studies We excluded one study because it had high risk of bias; we needed
further information before being able to include it (Scholler 1993).
Results of the search

The search identified 20 publications, of which we have included
Risk of bias in included studies
five studies that recruited 14,624 women, with data analysed for We assessed risk of bias of each included study according to the
14,185 women, and 20 meta-analyses. We have excluded eight Cochrane Handbook of Systematic Reviews of Interventions (Higgins
studies. For further details of trial characteristics, please refer to the 2009) and summarised in Figure 1.

Figure 1. Methodological quality summary: review authors’ judgements about each methodological quality
item for each included study.

Allocation
through the study.” This was considered to be a possible high risk
Two studies had adequate sequence generation and allocation con- of bias in this study.
cealment (Mason 1993; Newnham 1993). Whittle 1994 had ad-
equate allocation concealment but unclear sequence generation; Effects of interventions
the randomisation process for this trial led to very different group
sizes, which the authors attributed to problems with sequence (see See: Summary of findings for the main comparison All routine
the Characteristics of included studies for further detail). Neither Doppler ultrasound versus no Doppler ultrasound
Davies 1992 nor French Doppler 1997) described sequence gen-
eration, though in both trials, randomisation was conducted in
1) All routine Doppler ultrasound versus no Doppler
blocks and allocation concealment was adequate.
ultrasound (five studies, 14,185 women)
Five studies addressed this comparison (Davies 1992; French
Blinding Doppler 1997; Mason 1993; Newnham 1993; Whittle 1994).
All trials were assessed as of high risk of bias due to lack of blinding
of staff and participants. Whittle 1994 was assessed as unclear be- Primary outcomes
cause only women in the “revealed group had results recorded in
the case notes.” Staff would have been aware of group assignment
for a proportion of women in this trial, but it was unclear if blind- 1. Perinatal death (stillbirths and neonatal deaths including
ing would have functioned for those in the concealed ultrasound anomalies)
group.
Due to the large heterogeneity for this outcome (Tau² = 0.47; Chi²
All trials were assessed as of high risk of bias due to lack of blinding
= 9.22, df = 3 (P = 0.03); I² = 67%), we used a random-effects meta-
of outcomes assessors.
analysis. The average risk ratio (RR) across studies was (RR 0.80,
95% confidence interval (CI) 0.35 to 1.83); four studies, 11,183
Incomplete outcome data participants, Analysis 1.1), indicating that on average there is no
statistically significant reduction identified in the risk of perinatal
Four studies showed minimal loss of data either by withdrawal death when Doppler ultrasound is used. A prediction interval for
after randomisation or by loss to follow-up less than 6% (Davies the underlying relative risk in any future study is also very wide
1992; French Doppler 1997; Mason 1993; Newnham 1993). The (95% prediction interval = 0.03 to 24.87), reflecting the large
fifth study reported no loss of outcome data (Whittle 1994). heterogeneity identified and the small number of studies.
Selective reporting 2. Serious neonatal morbidity

Since we did not assess the trial protocols of the included studies, Based on a single study, there was no significant difference iden-
we cannot comment on whether all the prespecified outcomes are tified in serious neonatal morbidity (RR 0.99, 95% CI 0.06 to
reported on. We contacted authors for Newnham 1993 because 15.75; one study, 2016 participants, Analysis 1.2).
they mentioned collecting data that were not presented in usable
form for this review. We have not had a reply.
Secondary outcomes
We found few significant differences for the whole range of the sec-
Other potential sources of bias ondary outcomes (Analysis 1.3 to Analysis 1.20). Subgroup anal-
Three studies appeared to be free from other potential biases ( yses for stillbirth and for potentially preventable perinatal death
Davies 1992; French Doppler 1997; Newnham 1993) and for showed group differences, as described below.
one study this seemed unclear (Mason 1993). The fifth study was These analyses included the following mortality outcomes.
assessed as having high risk of bias in that there was a considerable • Any death after randomisation (average RR 0.81, 95% CI
difference in the numbers of women allocated to the two groups 0.44 to 1.49; Tau² = 0.25; I² = 74%; four trials, 11,183
(1642 and 1344), which probably indicates a problem with the participants; Analysis 1.3)
randomisation (Whittle 1994). This was discussed and explained • Stillbirth - Data for stillbirth were not pooled because there
by the authors as “...due to secretarial error in preparation of the was evidence of differences between subgroups (Chi² = 3.23, df =
envelopes ... previously used random numbers had been ‘recycled’ 1 (P = 0.07), I² = 69.0%). There could be important clinical

differences between women who received different Doppler • Preterm birth before 37 weeks (average RR 1.02, 95% CI
protocols. Subgroup analysis of fetal/umbilical vessels only 0.86 to 1.21; four studies, 12,162 participants; Analysis 1.17).
showed that Doppler may have improved rates of stillbirth Two trials studied fetal vessels only and two additional trials
(average RR 0.34, 95% CI 0.12 to 0.95; two trials, 6877 examined the fetal vessels + uterine artery; both subgroups had
participants), where the subgroup of fetal/umbilical vessels + substantial heterogeneity, but there was no evidence of subgroup
uterine artery found no group differences (average RR 1.41, differences.
95% CI 0.44 to 4.46; two trials, 5276 participants; • Neonatal admission to special care baby unit/neonatal
heterogeneity: Tau² = 0.44; I² = 63%; Analysis 1.4)). intensive care unit (RR 0.99, 95% CI 0.84 to 1.17; three studies,
• Neonatal death up to 28 days (RR 0.88, 95% CI 0.17 to 7477 participants; Analysis 1.18).
4.41; four studies, 11,183 participants; heterogeneity: Tau² = • Birthweight (g) (mean difference (MD) -17.55, 95% CI -
1.54; Chi² = 7.27, df = 3 (P = 0.06); I² = 59%; Analysis 1.5). 42.23 to 7.13; two studies, 5914 participants; Analysis 1.19).
Two studies assessed fetal vessels only and showed no statistically • Gestational age at birth (MD -0.08, 95% CI -0.16 to -0.00;
significant difference (French Doppler 1997; Mason 1993), two studies, 5914 participants; Analysis 1.20).
while two studies using a combination of fetal and utero-
placental Doppler (Davies 1992; Newnham 1993) showed no None of the included trials in this review reported the outcomes of
significant difference and large heterogeneity (Tau² = 3.75; Chi² neonatal seizures/fits, infant respiratory distress syndrome, meco-
= 5.69, df = 1 (P = 0.02); I² = 82%; Analysis 1.5). nium aspiration, or women’s views/satisfaction.
• Potentially preventable perinatal death - data for potentially
preventable perinatal death were not pooled because there was
2) Single Doppler ultrasound assessment versus no
evidence of subgroup differences (Chi² = 3.04, df = 1 (P = 0.08),
Doppler ultrasound (one study, 3898 women)
I² = 67.1%). There could be important clinical differences
between women who received different Doppler protocols. Two Only one study addressed this comparison (French Doppler
trials (French Doppler 1997; Whittle 1994) assessed fetal vessels 1997).
only (average RR 0.36, 95% CI 0.15 to 0.87, 6878 participants),
and for this subgroup the intervention seemed to make a
difference. Two other trials ( Davies 1992; Newnham 1993) Primary outcomes
assessed fetal and the uterine artery and found no group Fewer women in the single Doppler group experienced the out-
differences (average RR 1.74, 95% CI 0.37 to 8.06; 5276 come of perinatal death (stillbirth and neonatal death including
participants) and high heterogeneity (Tau² = 0.98; I² = 80%; anomalies) (RR 0.36, 95% CI 0.13 to 0.99; one study, 3891 par-
Analysis 1.6). ticipants; Analysis 2.1).
Serious neonatal morbidity was not assessed.
There were no significant group differences for any of the remain-
ing secondary outcomes, including the following:
• Fetal acidosis (RR 1.04, 95% CI 0.87 to 1.25; one study,
Secondary outcomes
1518 participants; Analysis 1.7).
• Apgar score less than seven at 5 minutes (RR 0.88, 95% CI There were significant group differences in rates of any death after
0.56 to 1.39; four studies, 11, 375 participants; Analysis 1.8). randomisation (RR 0.36, 95% CI 0.13 to 0.99; one study, 3891
• Caesarean section, elective and emergency (RR 0.98, 95% participants; Analysis 2.4).
CI 0.85 to 1.13; two studies, 6373 participants; Analysis 1.9). There were no statistically significant differences identified in any
• Elective caesarean section (RR 1.01, 95% CI 0.87 to 1.18; of the other secondary outcomes that were assessed (Analysis 2.2
four studies, 11,375 participants; Analysis 1.10). to Analysis 2.16).
• Emergency caesarean section (RR 0.93, 95% CI 0.74 to This one trial (French Doppler 1997) did not report the outcomes
1.18; two studies, 6373 participants; Analysis 1.11). of fetal acidosis, neonatal seizures/fits, infant respiratory distress
• Spontaneous vaginal birth (RR 0.99, 95% CI 0.96 to 1.02; syndrome, infant requiring intubation/ventilation, meconium as-
two studies, 6373 participants; Analysis 1.12). piration, neonatal admission to special care baby unit/neonatal
• Operative vaginal birth (RR 1.04, 95% CI 0.96 to 1.12; intensive care unit or women’s views/satisfaction.
two studies, 6884 participants; Analysis 1.13).
• Induction of labour (RR 1.04, 95% CI 0.97 to 1.12; four
studies 11,190 participants; Analysis 1.14). 3) Multiple Doppler ultrasound assessments versus no
• Neonatal resuscitation (RR 1.02, 95% CI 0.84 to 1.24; two Doppler ultrasound (three studies, 7301 women)
studies, 6373 participants; Analysis 1.15). Three studies addressed this comparison (Davies 1992; Mason
• Infant intubation/ventilation (RR 0.99, 95% CI 0.54 to 1993; Newnham 1993). One study combined the data from
1.81; one study, 2986 participants; Analysis 1.16). women having one assessment and some having more than one

assessment (Whittle 1994); these data are only included in Com- 1993; Whittle 1994). All trials had adequate allocation conceal-
parison 1 - ’All routine Doppler ultrasound versus no Doppler ment, but none had adequate blinding of participants, staff or
routine ultrasound’. outcome assessors. Overall and apart from lack of blinding, the
risk of bias for the included trials was considered to be low.
No differences in perinatal mortality were noted for the main
Primary outcomes comparison of all Doppler regimens versus no Doppler ultra-
For perinatal death, a random-effects meta-analysis showed that sound.There were no group differences noted for the review’s pri-
the average intervention effect across studies was not statistically mary outcomes of perinatal death and neonatal morbidity. Only
significant (average RR 1.04, 95% CI 0.40 to 2.66; three studies, one included trial assessed serious neonatal morbidity and found
7292 participants; Analysis 3.1). Perinatal deaths showed large no evidence of group differences.
heterogeneity (Tau² = 0.46; I² = 68%). The prediction interval for For the main comparison of ’All Doppler versus No Doppler’, sub-
the intervention effect in any future study was extremely wide. group analyses according to ultrasound regimen (fetal/umbilical
From a single study, Mason 1993, there were no significant group vessels only versus fetal/umbilical vessels and uterine artery) found
differences for the outcome of serious neonatal morbidity (RR evidence of group differences for two outcomes. A subgroup of
0.99, 95% CI 0.06 to 15.75; one study, 2016 participants; Analysis trials (French Doppler 1997; Whittle 1994) that examined fetal/
3.2). umbilical vessels only showed that Doppler made a difference in
the rates of stillbirth. These stillbirth results were not replicated in
the subgroup of trials (Davies 1992; Newnham 1993) that con-
Secondary outcomes sidered both fetal/umbilical vessels and the uterine artery. Data for
these subgroups were not pooled because there was evidence of
There were no statistically significant group differences for the
subgroup differences. Similarly, a subgroup of two trials (French
following mortality outcomes.
Doppler 1997; Whittle 1994) that assessed fetal/umbilical vessels
• Any death after randomisation (average RR 1.00, 95% CI
only showed a reduction in potentially preventable perinatal death.
0.55 to 1.80; three studies, 7292 participants; Heterogeneity:
However, two trials (Davies 1992; Newnham 1993) that assessed
Tau² = 0.13; I² = 49%; Analysis 3.3).
fetal vessels and the uterine artery found no evidence for group
• Stillbirth (average RR 1.41, 95% CI 0.44 to 4.46; two
differences in preventable deaths. Data for potentially preventable
studies, 5276 participants; Heterogeneity: Tau² = 0.44; I² =
perinatal death for all four studies were not pooled again, because
63%; Analysis 3.4). Both trials in this analysis examined the fetal
there was evidence of subgroup differences. There could be im-
vessels + uterine artery.
portant clinical differences between women who received different
• Neonatal death (average RR 1.42, 95% CI 0.16 to 12.36;
Doppler protocols for both of these outcomes. Finally, we would
three studies, 7292 participants; I² = 69%; Analysis 3.5).
also suggest caution when interpreting these results because these
• Potential preventable perinatal death (average RR 1.61,
are subgroup analyses of secondary outcomes with few trials per
95% CI 0.87 to 3.00; two studies, 5276 participants;
subgroup.
heterogeneity: Chi² = 4.99, I² = 80%); Analysis 3.6). Both trials
For the comparison of a single Doppler assessment versus no
in this analysis examined the fetal vessels + uterine artery.
Doppler, significant groups differences in perinatal death were also
There were no statistically significant differences identified in any detected. However, these results are based on a single trial, and we
of the other secondary outcomes which were assessed (Analysis 3.7 would recommend caution when interpreting this finding. Over-
to Analysis 3.17). all, the number of participants included in analyses in this re-
The trials did not report the outcomes of fetal acidosis, opera- view remains too small to detect small, but potentially significant
tive vaginal birth, infant requiring intubation/ventilation, neona- changes in perinatal outcome (Chalmers 1989). No differences in
tal seizures/fits, infant respiratory distress syndrome, meconium perinatal death were found for the final comparison of multiple
aspiration, or women’s views/satisfaction. Doppler assessments versus no Doppler.
The results from Davies for the outcome potentially preventable
perinatal death suggest that routine Doppler ultrasound in un-
selected pregnancies assessing both umbilical and uterine artery
Doppler may do more harm than good, but the authors acknowl-
DISCUSSION edged that the increase in perinatal deaths was an unexpected find-
ing and may have occurred by chance (Davies 1992). Further-
more, the authors state that the study was not designed to test
Summary of main results the ability of routine Doppler ultrasound examinations to reduce
perinatal mortality, because a much larger number of participants
This review includes data from 14,185 women from five stud-
would need to be included in a such a trial to test this hypothesis.
ies (Davies 1992; French Doppler 1997; Mason 1993; Newnham

There was no evidence of group differences for the outcomes of heterogeneity and for imprecision, while serious neonatal morbid-
caesarean section, neonatal intensive care admissions or preterm ity was downgraded for imprecision. Evidence for the outcome of
birth less than 37 weeks. stillbirth was graded according to regimen subgroups. We assessed
We would like to note that In the Perth study (Newnham 1993), stillbirth (fetal/umbilical vessels only) as of moderate quality due
there was an unexpected finding of a greater risk of intrauterine to potential risk of bias in the contributing trial, and stillbirth (fe-
growth restriction in the serial ultrasound and Doppler examina- tal/umbilical vessels + uterine artery vessels) received a low quality
tion group (i.e. the intensive monitoring group). The authors re- rating due to imprecision and heterogeneity. Evidence for admis-
port, “A written diagnosis of intrauterine growth restriction was sion to neonatal intensive care unit was assessed as of moderate
observed more frequently in the medical records of women in the quality (downgraded once for potential risk of bias), and evidence
intensive group than in the regular group (relative risk 2.07; 95% for the outcomes of caesarean section and preterm birth less than
CI 1.34 to 3.21),” but they do not provide data in a format in 37 weeks was graded as of high quality. Please see the Summary
which we can include in our review. (We have written to the au- of findings for the main comparison below.
thors and to the Lancet to try to obtain these data.) The authors
state that multiple logistic regression analyses indicated that this
was probably not a chance effect, and it is possible that frequent
exposure to ultrasound may have influenced fetal growth. This Potential biases in the review process
finding was not associated with increased perinatal morbidity and
Evidence in this review was derived from studies identified in a
mortality, and follow-up of these children at one year of age found
detailed search process. Trials comparing interventions of Doppler
that the difference in growth was no longer discernible (Newnham
ultrasound versus no Doppler that have not been published may
1996). This is, however, a further finding which suggests more
not have been identified. We attempted to minimise bias in the
harm than good, and the authors stress the need for further in-
review process by having two review authors independently extract
vestigation of the effects of frequent ultrasound exposure on fetal
data.
growth.
Overall completeness and applicability of Agreements and disagreements with other

evidence studies or reviews
Routine fetal and umbilical Doppler ultrasound examination in A brief literature search identified very few recent systematic re-
low-risk or unselected populations did not result in increased an- views on the use of Doppler ultrasound in low risk populations.
tenatal, obstetric and neonatal interventions, and no overall differ- Studying unselected or low-risk populations, Goffinet 1997 found
ences were detected for substantive short-term clinical outcomes no group differences between women who received Doppler or
such as perinatal mortality. There is no available evidence to assess no Doppler. In a trial of the use of Doppler for multiple preg-
the effect on substantive long-term outcomes such as childhood nancy, Giles 2003 found similar rates of antenatal, peripartum and
neurodevelopment and no data to assess maternal outcomes, par- neonatal outcomes, including unexplained fetal death, in women
ticularly psychological effects. who received Doppler or no Doppler. Stampalija 2010 also iden-
Future studies should be designed to address small changes in tified no benefit to women or infants from Doppler ultrasound in
perinatal outcome, and should focus on potentially preventable the second trimester for women at low risk of hypertensive dis-
deaths orders. A retrospective cohort study (Morales-Rosello 2014) sug-
gested that Doppler may be useful for detecting appropriate for
gestational age fetuses who do not reach growth potential at term.
Quality of the evidence In an overview of recent research in low- and high-risk women,
O’Connor 2013 concluded that the use of Doppler measures in
We included five trials that recruited 14,624 women, with data
“appropriately grown and large for gestational age fetuses has yet
analysed for 14,185 women. All trials had adequate allocation
to be fully validated.” The wider literature corroborates the results
concealment, but none had adequate blinding of participants, staff
of our review on the use of Doppler in low-risk or unselected pop-
or outcome assessors. Overall, and apart from lack of blinding,
ulations.
the risk of bias for the included trials was considered to be low.
For GRADE assessments, we did not downgrade the evidence for
specific outcomes for all trials’ lack of blinding.
When evidence quality was assessed with GRADE software, the
outcomes of perinatal death and serious neonatal morbidity data
were graded as of low quality. Perinatal death was downgraded for AUTHORS’ CONCLUSIONS

Implications for practice ACKNOWLEDGEMENTS
When we take into account the perinatal mortality including We are grateful to Professor AM Weindling (Professor of Perinatal
anomalies, there is no conclusive evidence that Doppler ultra- Medicine, University of Liverpool) for advice on neonatal out-
sound makes a difference. There is some evidence that umbilical comes to the authors of the original version of this review (Bricker
artery Doppler velocimetry may reduce the risk of potentially pre- 2007). Also to Dr JA Davies, and to Professor J Newnham and
ventable perinatal deaths. However, these findings are based on Dr Sharon Evans for also providing further information on their
few trials and subgroup analyses. For these reasons, we conclude trials (Davies 1992; Newnham 1993) to the authors of the original
that existing data do not provide robust enough evidence that the version of this review (Bricker 2007).
use of routine umbilical artery Doppler ultrasound, or combina-
Our thanks to Leanne Bricker, James P Neilson and Gill Gyte for
tion of umbilical and uterine artery Doppler ultrasound in low-
their work on the previous version of this review.
risk or unselected populations benefits either mother or baby. Un-
til further research can support new practices, Doppler ultrasound Richard Riley who provided help with the statistical analysis, in
examination should be reserved for use in high-risk pregnancies particular with the random-effects analyses and prediction inter-
(Alfirevic 2013). vals.
Nancy Medley’s work was financially supported by the UNDP/
Implications for research
UNFPA/UNICEF/WHO/World Bank Special Programme of Re-
If there is to be future research into fetal and umbilical Doppler search, Development and Research Training in Human Reproduc-
ultrasound examination in low-risk or unselected populations, a tion (HRP), Department of Reproductive Health and Research
large trial with adequate power to test hypotheses related to peri- (RHR), World Health Organization. The named authors alone
natal outcome is required. Trials should focus on potentially pre- are responsible for the views expressed in this publication.
ventable deaths and inclusion criteria should reflect that. It would
This project was supported by the National Institute for Health
also be important to include assessment of neurodevelopment and
Research, via Cochrane Infrastructure funding to Cochrane Preg-
assessment of maternal outcomes and psychological effects on the
nancy and Childbirth. The views and opinions expressed therein
mother.
are those of the authors and do not necessarily reflect those of the
Several of our prespecified secondary outcomes were not measured Systematic Reviews Programme, NIHR, NHS or the Department
in any trial included in this review. of Health.
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∗
and birthweight, childhood malignancies and neurological Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Davies 1992
Methods Randomised controlled trial. Individual women. Queen Charlotte’s and Chelsea Hospi-
tal, London, UK
Participants Inclusion criteria

• Pregnant women, with singleton pregnancies, at 19-22 weeks pregnant.
• Unselected.
• Low- and high-risk pregnancies: high risk 189 in Doppler group and 192 in
control group.
• 2600 women - 79% of eligible population.
Exclusion criteria
• Multiple pregnancies.
Interventions Experimental intervention: Doppler ultrasound of umbilical-artery and uterine-artery

• Multiple assessments at 20 and 32 weeks.
• Women with low-risk pregnancies had Doppler at booking and 32 weeks. Low
risk for SGA or other compromised infant.
• Women at high risk had ultrasound every month. High risk = women identified
before entry into trial by: pre-existing medical condition, e.g. hypertension, diabetes,
previous SGA baby, previous stillbirth pr neonatal death, hypertension (BP > 140/90
mmHg) in previous pregnancy or at booking, smoking > 10 a day.
• Any women in low-risk group who had abnormal Doppler was managed
subsequently as high risk. If subsequent examination was normal the woman
transferred back to low-risk group.
• Clinician could have Doppler at other times as requested.
• N = 1246.
Control/Comparison intervention: no Doppler ultrasound
• Intended that women should not have Doppler US at anytime in pregnancy.
• Normal AN care with no Doppler.
• N = 1229.
Multiple estimations were at 20 and 32 weeks’ gestation.
Sample size calculation “to have an 80% chance at the 5% level of significance of demon-
strating a 20% reduction in antenatal admissions during pregnancy in the doppler group.
”
Outcomes Number of days of antenatal admission; number of CTG recordings and US scans; ges-
tational age at birth; mode of birth; birthweight; Apgar scores; need for resuscitation
(intermittent positive pressure ventilation either via a mask or endotracheal tube); ad-
mission to NICU; fetal and neonatal outcomes
The study was not designed to test the ability of Doppler ultrasound to reduce PNM, so
the fact that there were more preventable deaths in the Doppler group is likely to be due
to chance. However, the authors do theorise that it is possible that a woman’s knowledge
of a normal result may have resulted in her taking less notice of symptoms that might
otherwise have resulted in a review of fetal well-being

Davies 1992 (Continued)
Notes London (UK) 1992 study in previous version of the review (Bricker 2007).
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection Unclear risk Sequence generation not described; ran-
bias) domisation conducted in blocks of 500 and
200
Allocation concealment (selection bias) Low risk Allocation “by cards in sealed opaque en-
velopes.”
Blinding of participants and personnel High risk Blinding not possible.

(performance bias)
All outcomes
Blinding of outcome assessment (detection High risk Blinding not possible.

bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk Describe any loss of participants to follow-
All outcomes up at each data collection
point.
Describe any exclusion of participants after
randomisation:
• 125 women (4.8%) were excluded
because: 106 gave birth elsewhere; 8 were
randomised then found to have missed
abortion; 2 multiple pregnancies; or
because randomisation care (7), Doppler
data (1) or hospital notes (1) went
missing. Demographics similar to rest of
study population .
Was the analysis ITT? If not, have the data
been able to be re-included?
• Loss was small and unlikely to
impact on outcomes.
Selective reporting (reporting bias) Unclear risk There are discrepancies in the numbers
of neonatal deaths between reports of
this trial. We have used the numbers re-
ported in the Lancet 1992 article, including
early neonatal deaths added together with
neonatal deaths
Other bias Low risk If the study was stopped early, explain the
reasons:
• Not stopped earlier.

Davies 1992 (Continued)
Describe any baseline imbalance:

• “Women in the Doppler and the
control groups did not differ in their
demographic details (Table 1)”. So
assessed by age, weight at booking, ethnic
origins, nulliparous, smoking, shared
antenatal care, high risk.
• 15 (1.2%) of the 1229 women in the
control group had Doppler.
Describe any differential diagnosis:
• Seems fine.
French Doppler 1997
Methods Multicentre randomised controlled trial. Individual women. Randomisation in blocks

of 4

• Women attending routine AN visit between 28-34 weeks who had a normal US
scan (fetal biometry above 10th centile of reference curve).
• N = 4187 randomised with 3898 analysed.
Exclusion criteria
• Women who had indications for Doppler at last 2nd trimester appointment, e.g.
medical history of hypertension, diabetes, previous fetal death, IUGR, hypertensive
disorder of pregnancy, treatment with beta agonists, insulin-dependent diabetes.
• Women who at their last second trimester appointment had indications for
umbilical Doppler.
• Women who had undergone an umbilical Doppler before 28 weeks for any reason
whatever.
Interventions Experimental intervention: umbilical Doppler ultrasound

• Single assessment at 28-34 weeks.
• Umbilical Doppler US on day of randomisation, immediately after ultrasound
scan monitoring fetal growth.
• All further tests performed at clinicians’ request according to standard practices in
their AN clinics.
• N = 2099 with 1950 analysed.
Control/comparison intervention: no Doppler ultrasound
• No Doppler US on day of randomisation. Access to Doppler studies was allowed
on obstetrician’s request.
• N = 2088 with 1948 analysed.
Single estimation between 28-34 weeks.
Outcomes • AN consultations; days of AN hospitalisation; CTG; ultrasound and Doppler

tests.
• Peri- and neonatal deaths; FD; Apgars; neonatal resuscitation; neonatal transfer;
birthweight; SGA.
• Disorders occurring after randomisation e.g. PIH; pre-eclampsia, uterine
bleeding, oligohydramnios, suspected IUGR, abnormal CTG patterns.

French Doppler 1997 (Continued)
Notes France 1997 study in previous version of the review (Bricker 2007).
Authors did report umbilical cord pH < 7.20 but only on a subsample of women and
the groups were not randomised groups. Findings were: Doppler 188 / 757 (24.8%) and
no Doppler 181/761 (23.8%)
Risk of bias
Random sequence generation (selection Unclear risk “...randomly divided...” Central randomi-
bias) sation in blocks of four. Sequence genera-
tion not described
Allocation concealment (selection bias) Low risk • “The randomisation procedure using
sealed envelopes was standard in each
centre and was carried out by the
ultrasonographer immediately after
verification of the inclusion criteria and
performance of the standard ultrasound
scan. The envelopes were prepared
centrally and were sent to each centre
consecutively numbered.” No ‘opaque’
mentioned.
• “The randomisation sequence was
verified in two ways. After the end of the
study every centre was asked to send back
the enveloped that had not been used. It
was also checked that the envelopes were
used in ascending order.”
• Blocks of 4 means that the sequence
may have been predicted for at least 1/4 of
women. However, with central
randomisation and sealed envelopes there
is no risk of bias.
Blinding of participants and personnel High risk Blinding not possible.

(performance bias)
All outcomes

bias)
All outcomes
All outcomes up at each data collection point:
• 174 women lost to follow-up.
Doppler; 25 (1.2%) lost just after
randomisation and 66 (3.3%) data were
not available for analysis. No Doppler: 27

French Doppler 1997 (Continued)
(1.3%) lost just after randomisation and

56 (2.8%) data were not available for
analysis.
randomisation:
• 115 were excluded (58 (2.8%) in
Doppler and 57 (2.7%) in No Doppler.
All these women were from 3 centres
where randomisation was not undertaken
properly in that envelopes were not used
in ascending order.
Was the analysis ITT? If not has the data
• Appears to be ITT and losses are
only small % and evenly distributed
between the 2 groups.
Selective reporting (reporting bias) Unclear risk We have not assessed the trial protocol.
Other bias Low risk There appear to be no other biases.
Mason 1993
Methods Randomised controlled trial, individual women.

• Primagravida women with a negative medical and gynaecological history and
physical examinations were identified at booking clinic.
• N = 2145 were randomised but 2025 analysed.
Exclusion criteria
• Twin pregnancies.
Interventions Experimental intervention: umbilical artery Doppler ultrasound

• Multiple at 28 weeks and again at 34 weeks.
• N = 1073.
Control/comparison intervention: routine care, no Doppler ultrasound
• Clinician could request Doppler if felt indicated. 3.9% (42 women) were referred
for Doppler US.
• N = 1072.
Multiple estimations were at 28 and 34 weeks’ gestation.
Outcomes Main outcome: obstetric intervention rate, short-term neonatal morbidity
Notes Leeds (UK) 1993 study in previous version of the review (Bricker 2007).
Risk of bias

Mason 1993 (Continued)
Random sequence generation (selection Low risk ”Tables of random numbers were used to
bias) generate each random permuted block.”
Allocation concealment (selection bias) Low risk “...opaque numbered envelopes which were
opened on the fetal assessment unit by a
radiographer who had no personal knowl-
edge of the women or her history.”
No mention if envelopes were sealed.
Blinding of participants and personnel High risk Blinding not possible. Women in treatment
(performance bias) group sent a letter to schedule appoint-
All outcomes ments

bias)
All outcomes
• 53/1073 (5%) women in Doppler
were lost to follow-up due to abortion
before testing or move from study area.
• 67/1072 (6%) women in No
Doppler were lost to follow-up due to
abortion before testing or move from
study area.
randomisation:
• 5 sets of twins were excluded from
Doppler and 4 from control.
Denominators for outcome data used were
1015 treatment and 1001 control
Selective reporting (reporting bias) Unclear risk We did not assess the trial protocol.
Other bias Unclear risk If the study was stopped early, explain the
reasons:
• Not stopped early for benefit or
harm.
Describe any baseline in balance:
• Balanced according to: age, weight
before pregnancy, primapara, educational
level, gestational age at inclusion,
biparietal diameter, transverse abdominal
diameter.
• 863 (80%) of those offered Doppler
attended for assessment. In the control
group 42 (3.9%) women were referred for

Mason 1993 (Continued)
a total of 191 Doppler assessments.

• The relatively lower compliance at
34 weeks than at 28 weeks was probably
related to the hospital policy of a routine
visit at 28 weeks but not at 34 weeks.
• Seems ok.
Newnham 1993
Methods Randomised controlled trial. Individual women.

• Pregnant women, gestational age 16-20 weeks. Sufficient proficiency in English,
expected to give birth in hospital and expected to remain in the Western Australia for
childhood follow-up.
• N = 2834 with data available on 2801.
Interventions Experimental intervention: umbilical and uterine Doppler US - intense monitoring

group
• The intense group had ultrasound imaging and Doppler flow studies at
approximately 18 weeks and then at 24, 28, 34 and 38 weeks.
• Umbilical artery and arcuate artery within the placental vascular bed.
• N = 1415.
Control/Comparison intervention: no Doppler US - regular group
• Ultrasound scan at 18 weeks and any other tests only done at request of clinician.
• N = 1419.
Multiple estimations were at 18, 24, 28, 34 and 38 weeks’ gestation
Outcomes Induction of labour; caesarean section; ultrasound information
Notes Perth (Aus) 1993 study in previous version of the review (Bricker 2007).
Authors report an increase in IUGR with the Doppler group (RR 2.07, 95% CI 1.34 to
3.21) but do not provide the data for us to enter into RevMan. They report ”Multiple
logistic regression analyses showed that the increased proportion of growth-restricted
fetuses in the intensive arm was not due to a chance effect from differential clustering
within the two groups...“ though they go on to say that while this may have been a chance
finding, it is possible that frequent exposure to ultrasound has influenced fetal growth.
This finding was not associated with increased perinatal morbidity and mortality, and
follow-up of these children at 1 year of age found that the difference in growth was no
longer discernible. We are trying to contact the authors and are writing to the journal to
seek further data
At the update of this review (2014) there has been no reply from authors
Stoch 2012 reports 2 long term outcomes at 20-year follow-up: diagnosis of Austism
Spectrum Disorder and autistic-like traits in adults without a diagnosis (Autism spectrum
quotient or AQ)
Risk of bias

Newnham 1993 (Continued)
Random sequence generation (selection Low risk “...computer generated random numbers..
bias) .”
Allocation concealment (selection bias) Low risk • ”..the woman was allocated to a
group by a sealed-envelope technique
prepared in blocks of 20.
Blinding of participants and personnel High risk Women and staff aware of group as-
(performance bias) signment. “Results of all ultrasound and
All outcomes Doppler flow studies were shown to the
women and records were placed in the hos-
pital chart.”
Blinding of outcome assessment (detection High risk Pregnancy outcome data “taken from hos-
bias) pital notes.” Outcome assessors were likely
All outcomes aware of group assignment
• 13/1415 (1%) in Doppler and 20/
1419 (1%) in no Doppler.
randomisation:
• Appeared to be none.
• 66 (2.3%) multiple pregnancies
excluded but we think before
randomisation.
Was the analysis ITT? If not has the data
• Appears to be ITT.
Selective reporting (reporting bias) Unclear risk We did not assess the trial protocol. Re-
quests for additional data (see above) have
not been successful
Other bias Low risk If the study was stopped early, explain the
reasons:
• Not stopped early for benefit or
harm.
• Groups similar in terms of: age,
height, weight, marital status, race, parity,
poor obstetric history and smoking.
• 114 (intensive 50 and regular 64)
women delivered in other hospitals and
their outcomes were still assessed.

Newnham 1993 (Continued)

• Seems ok.
Whittle 1994
Methods Randomised controlled trial. Individual women.

• Unselected population.
• Women attending the AN before 26 weeks’ gestation, there was no attempt at
selection, so women were eligible for inclusion, regardless of whether they had high-
risk features).
Exclusion criteria
• Multiple pregnancies.
Interventions Experimental intervention: umbilical Doppler US revealed

• Umbilical artery systolic/diastolic ratio revealed.
• Doppler screening US made available from 26 to 30 weeks (1st window) and 34
to 36 weeks (2nd window).
• N = 1642.
Control/Comparison intervention:
• Doppler screening US concealed.
• N = 1344.
Multiple estimations were at 26-30 weeks and 34-36 weeks. Of the 2986 women in the
study, 1386 underwent examination at both gestational windows, 1056 at only the first
and 544 at only the second
Outcomes Antenatal complications; antenatal admissions; day care visits; elective delivery; elective
CS; CS in labour; CS for FD; birth < 32 weeks; Apgar scores; small for dates; admission
to SCBU; ventilations; stillbirth
Notes Glasgow (UK) 1994 study in previous version of the review (Bricker 2007).
Risk of bias
Random sequence generation (selection Unclear risk “the order was generated by random-num-
bias) ber tables.” Authors report some problems
with randomisation that led to unequal
treatment groups. See Other Bias below
Allocation concealment (selection bias) Low risk “sealed opaque envelopes” “numbered.”
Blinding of participants and personnel Unclear risk Women recruited into “revealed or con-
(performance bias) cealed groups”; All women had Doppler
All outcomes ultrasonography, but “only the revealed
group had results recorded in the case notes.

Whittle 1994 (Continued)
” Staff would have been aware of group as-

signment for a proportion of women if they
were allowed to request Doppler results for
the ’revealed’ group
Blinding of outcome assessment (detection High risk Study unblinded.

bias)
All outcomes
• No dropouts (in comment).
randomisation:
• Not specified.
Selective reporting (reporting bias) Unclear risk We did not assess the trial proto-
col.
Other bias High risk If the study was stopped early, explain the
reasons:
• Not stopped earlier.
• Numbers of women in each group
were not similar - see below. Groups were
similar for parity and gestational age. The
difference in age was small 27.9 vs 27.2
but it was statistically significant. There
were more abnormal Doppler at the first
window (26 to 30 weeks) namely 33 for
revealed and 148 for concealed but similar
numbers at the 2nd window (34-36
weeks) namely 69 for revealed and 66 for
concealed.
• Groups were well matched except for
abnormal Doppler at first window. “It is
possible that this may have occurred
through unintentionally less persistent
attempts to obtain a normal waveform in
the concealed group than in the revealed
group. If this did occur, however, one
would have expected to see evidence of
the same trend at the second screen, and
this was not so.”
Also:
• The numbers in each group were not
similar (1642 vs 1344) suggesting a

Whittle 1994 (Continued)
problem with the randomisation. The

authors also noticed this and reported “...
due to secretarial error in preparation of
the envelopes...previously used random
numbers had been ‘recycled’ through the
study”.
AN: antenatal
BP: blood pressure
CI: confidence interval
CTG: cardiotocography
CS: caesarean section
FD: fetal distress
ITT: intention-to-treat
IUGR: intrauterine growth restriction
NICU: neonatal intensive care unit
PIH: pregnancy-induced hypertension
PNM: perinatal mortality
RR: risk ratio
SCBU: special care baby unit
SGA: small-for-gestational age
US: ultrasound
VS: versus
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Ellwood 1997 Trial studied uterine Doppler ultrasound and not fetal and umbilical
Goffinet 2001 Trial studied uterine Doppler ultrasound and not fetal and umbilical
Gonsoulin 1991 Conference abstract - not clear whether high-risk/low-risk/unselected pregnancies, and no data suitable for inclu-
sion. Further details were sought from the authors by the authors of the previous version of this review (L Bricker
and JP Neilson), without success.
Schneider 1992 Conference abstract in English language identified - unexplained difference in numbers (250 vs 329) in Doppler
vs control groups suggesting allocation bias. The definitive publication after translation from German did not
explain this difference and failed to outline the trial methodology
Scholler 1993 This study was translated from German for us. It was a quasi-RCT of 211 women undergoing Doppler ultrasound
vs no Doppler ultrasound. It was excluded for a combination of the following reasons: the only outcome relevant
to our review was induction of labour; the study had high risk of bias being a quasi-RCT; further information
was needed from the authors before these data could be included. Data reported for induction of labour: Doppler
group 37/108 and no Doppler group 41/103

(Continued)
Snaith 2006 Trial studied uterine Doppler ultrasound and not fetal and umbilical
Subtil 2000 Trial studied uterine Doppler ultrasound and not fetal and umbilical
Subtil 2003 Trial studied uterine Doppler ultrasound and not fetal and umbilical
RCT: randomised controlled trial

vs: versus

DATA AND ANALYSES
Comparison 1. All routine Doppler ultrasound versus no Doppler ultrasound
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Perinatal death (stillbirth and 4 11183 Risk Ratio (M-H, Random, 95% CI) 0.80 [0.35, 1.83]
neonatal death including
anomalies)
1.1 Fetal/umbilical vessels 2 5907 Risk Ratio (M-H, Random, 95% CI) 0.48 [0.21, 1.07]
only
1.2 Fetal/umbilical vessels + 2 5276 Risk Ratio (M-H, Random, 95% CI) 1.16 [0.29, 4.56]
uterine artery
2 Serious neonatal morbidity 1 2016 Risk Ratio (M-H, Fixed, 95% CI) 0.99 [0.06, 15.75]
2.1 Fetal/umbilical vessels 1 2016 Risk Ratio (M-H, Fixed, 95% CI) 0.99 [0.06, 15.75]
only
2.2 Fetal/umbilical vessels + 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
uterine artery
3 Any death after randomisation 4 11183 Risk Ratio (M-H, Random, 95% CI) 0.81 [0.44, 1.49]
(non-prespecified)
only
uterine artery
4 Stillbirth 4 Risk Ratio (M-H, Random, 95% CI) Subtotals only
only
uterine artery
5 Neonatal death (up to 28 days) 4 11183 Risk Ratio (M-H, Random, 95% CI) 0.88 [0.17, 4.41]
only
uterine artery
6 Potentially preventable perinatal 4 Risk Ratio (M-H, Random, 95% CI) Subtotals only
death
only
uterine artery
7 Fetal acidosis 1 1518 Risk Ratio (M-H, Fixed, 95% CI) 1.04 [0.87, 1.25]
only
uterine artery
8 Apgar score < 7 at 5 minutes 4 11375 Risk Ratio (M-H, Fixed, 95% CI) 0.88 [0.56, 1.39]
only
uterine artery
9 Caesarean section (elective and 2 6373 Risk Ratio (M-H, Fixed, 95% CI) 0.98 [0.85, 1.13]
emergency)
only
uterine artery
10 Elective caesarean section 4 11375 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.87, 1.18]
only
uterine artery
11 Emergency caesarean section 2 6373 Risk Ratio (M-H, Fixed, 95% CI) 0.93 [0.74, 1.18]
only
uterine artery
12 Spontaneous vaginal birth 2 6373 Risk Ratio (M-H, Fixed, 95% CI) 0.99 [0.96, 1.02]
only
uterine artery
13 Operative vaginal birth 2 6884 Risk Ratio (M-H, Fixed, 95% CI) 1.04 [0.96, 1.12]
only
uterine artery
14 Induction of labour 4 11190 Risk Ratio (M-H, Fixed, 95% CI) 1.04 [0.97, 1.12]
only
uterine artery
15 Neonatal resuscitation 2 6373 Risk Ratio (M-H, Fixed, 95% CI) 1.02 [0.84, 1.24]
only
uterine artery
16 Infant intubation/ventilation 1 2986 Risk Ratio (M-H, Fixed, 95% CI) 0.99 [0.54, 1.81]
only
uterine artery
17 Preterm birth (before 37 weeks) 4 12162 Risk Ratio (M-H, Random, 95% CI) 1.02 [0.86, 1.21]
only
uterine artery
18 Neonatal admission to 3 7477 Risk Ratio (M-H, Fixed, 95% CI) 0.99 [0.84, 1.17]
SCBU/NICU

only
uterine artery
19 Birthweight 2 5914 Mean Difference (IV, Fixed, 95% CI) -17.55 [-42.23, 7.
13]
19.1 Fetal/umbilical vessels 2 5914 Mean Difference (IV, Fixed, 95% CI) -17.55 [-42.23, 7.
only 13]
19.2 Fetal/umbilical vessels + 0 0 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
uterine artery
20 Gestational age at birth 2 5914 Mean Difference (IV, Fixed, 95% CI) -0.08 [-0.16, -0.00]
20.1 Fetal/umbilical vessels 2 5914 Mean Difference (IV, Fixed, 95% CI) -0.08 [-0.16, -0.00]
only
uterine artery
Comparison 2. Single Doppler ultrasound assessment versus no Doppler ultrasound
No. of No. of
1 Perinatal death (stillbirth and 1 3891 Risk Ratio (M-H, Fixed, 95% CI) 0.36 [0.13, 0.99]
anomalies)
only
uterine artery
2 Stillbirth 1 3891 Risk Ratio (M-H, Fixed, 95% CI) 0.40 [0.08, 2.05]
only
uterine artery
3 Neonatal death (up to 28 days 1 3891 Risk Ratio (M-H, Fixed, 95% CI) 0.25 [0.03, 2.23]
after birth)
only
uterine artery
4 Any death after randomisation 1 3891 Risk Ratio (M-H, Fixed, 95% CI) 0.36 [0.13, 0.99]
(non-prespecified)
only
uterine artery
5 Potentially preventable perinatal 1 3892 Risk Ratio (M-H, Fixed, 95% CI) 0.33 [0.11, 1.03]
death
only
uterine artery
only
uterine artery
emergency)
only
uterine artery
only
uterine artery
only
uterine artery
only
uterine artery
11 Operative vaginal birth 1 3898 Risk Ratio (M-H, Fixed, 95% CI) 1.10 [0.95, 1.26]
only
uterine artery
only
uterine artery
only
uterine artery
14 Preterm birth (before 37 weeks) 1 3898 Risk Ratio (M-H, Fixed, 95% CI) 1.20 [0.86, 1.69]
only
uterine artery

94]
only 94]
uterine artery
16 Gestational age at birth 1 3898 Mean Difference (IV, Fixed, 95% CI) -0.10 [-0.19, -0.01]
16.1 Fetal/umbilical vessels 1 3898 Mean Difference (IV, Fixed, 95% CI) -0.10 [-0.19, -0.01]
only
uterine artery
Comparison 3. Multiple Doppler ultrasound assessments versus no Doppler ultrasound
No. of No. of
1 Perinatal death (stillbirth and 3 7292 Risk Ratio (M-H, Random, 95% CI) 1.04 [0.40, 2.66]
anomalies)
only
uterine artery
2 Serious neonatal morbidity 1 2016 Risk Ratio (M-H, Fixed, 95% CI) 0.99 [0.06, 15.75]
only
uterine artery
3 Any death after randomisation 3 7292 Risk Ratio (M-H, Random, 95% CI) 1.00 [0.55, 1.80]
(non-prespecified)
only
uterine artery
4 Stillbirth 2 5276 Risk Ratio (M-H, Random, 95% CI) 1.41 [0.44, 4.46]
only
uterine artery
5 Neonatal death (up to 28 days) 3 7292 Risk Ratio (M-H, Random, 95% CI) 1.42 [0.16, 12.36]
only
uterine artery
6 Potentially preventable perinatal 2 5276 Risk Ratio (M-H, Fixed, 95% CI) 1.61 [0.87, 3.00]
death
only
uterine artery
only
uterine artery
emergency)
only
uterine artery
only
uterine artery
only
uterine artery
only
uterine artery
only
uterine artery
only
uterine artery
14 Preterm birth (before 37 weeks) 3 8264 Risk Ratio (M-H, Fixed, 95% CI) 0.97 [0.82, 1.15]
only
uterine artery
15 Neonatal admission to 2 4491 Risk Ratio (M-H, Fixed, 95% CI) 0.97 [0.71, 1.34]
SCBU/NICU
only
uterine artery
23]

only 23]
uterine artery
17 Gestational age at birth 1 2016 Mean Difference (IV, Fixed, 95% CI) -0.02 [-0.19, 0.15]
17.1 Fetal/umbilical vessels 1 2016 Mean Difference (IV, Fixed, 95% CI) -0.02 [-0.19, 0.15]
only
uterine artery
Analysis 1.1. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 1
Perinatal death (stillbirth and neonatal death including anomalies).
Review: Fetal and umbilical Doppler ultrasound in normal pregnancy
Comparison: 1 All routine Doppler ultrasound versus no Doppler ultrasound
Outcome: 1 Perinatal death (stillbirth and neonatal death including anomalies)
Study or subgroup Doppler No Doppler Risk Ratio Weight Risk Ratio

M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI
1 Fetal/umbilical vessels only

French Doppler 1997 5/1948 14/1943 24.0 % 0.36 [ 0.13, 0.99 ]
Mason 1993 4/1015 5/1001 19.3 % 0.79 [ 0.21, 2.93 ]
Subtotal (95% CI) 2963 2944 43.3 % 0.48 [ 0.21, 1.07 ]

Total events: 9 (Doppler), 19 (No Doppler)
Heterogeneity: Tau2 = 0.0; Chi2 = 0.88, df = 1 (P = 0.35); I2 =0.0%
Test for overall effect: Z = 1.78 (P = 0.074)
2 Fetal/umbilical vessels + uterine artery
Davies 1992 17/1246 7/1229 26.5 % 2.40 [ 1.00, 5.76 ]
Newnham 1993 13/1402 22/1399 30.1 % 0.59 [ 0.30, 1.17 ]
Subtotal (95% CI) 2648 2628 56.7 % 1.16 [ 0.29, 4.56 ]

Heterogeneity: Tau2 = 0.82; Chi2 = 6.13, df = 1 (P = 0.01); I2 =84%
Total (95% CI) 5611 5572 100.0 % 0.80 [ 0.35, 1.83 ]
Test for subgroup differences: Chi2 = 1.17, df = 1 (P = 0.28), I2 =14%
0.01 0.1 1 10 100

Favours Doppler Favours no Doppler

Serious neonatal morbidity.
Outcome: 2 Serious neonatal morbidity

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Mason 1993 1/1015 1/1001 100.0 % 0.99 [ 0.06, 15.75 ]
Subtotal (95% CI) 1015 1001 100.0 % 0.99 [ 0.06, 15.75 ]

Heterogeneity: not applicable
Subtotal (95% CI) 0 0 Not estimable
Test for overall effect: not applicable
Total (95% CI) 1015 1001 100.0 % 0.99 [ 0.06, 15.75 ]
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100


Analysis 1.3. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 3 Any
death after randomisation (non-prespecified).
Outcome: 3 Any death after randomisation (non-prespecified)

M- M-
n/N n/N CI CI

French Doppler 1997 5/1948 14/1943 20.0 % 0.36 [ 0.13, 0.99 ]
Mason 1993 4/1015 5/1001 14.6 % 0.79 [ 0.21, 2.93 ]
Subtotal (95% CI) 2963 2944 34.5 % 0.48 [ 0.21, 1.07 ]

Davies 1992 22/1246 13/1229 29.1 % 1.67 [ 0.84, 3.30 ]
Newnham 1993 30/1402 41/1399 36.3 % 0.73 [ 0.46, 1.16 ]
Subtotal (95% CI) 2648 2628 65.5 % 1.06 [ 0.47, 2.38 ]

Total (95% CI) 5611 5572 100.0 % 0.81 [ 0.44, 1.49 ]
0.01 0.1 1 10 100


Stillbirth.
Outcome: 4 Stillbirth

M- M-
n/N n/N CI CI

French Doppler 1997 2/1948 5/1943 39.5 % 0.40 [ 0.08, 2.05 ]
Whittle 1994 3/1642 8/1344 60.5 % 0.31 [ 0.08, 1.15 ]
Subtotal (95% CI) 3590 3287 100.0 % 0.34 [ 0.12, 0.95 ]

Davies 1992 11/1246 4/1229 44.4 % 2.71 [ 0.87, 8.50 ]
Newnham 1993 10/1402 12/1399 55.6 % 0.83 [ 0.36, 1.92 ]
Subtotal (95% CI) 2648 2628 100.0 % 1.41 [ 0.44, 4.46 ]

0.01 0.1 1 10 100


Neonatal death (up to 28 days).
Outcome: 5 Neonatal death (up to 28 days)

M- M-
n/N n/N CI CI

French Doppler 1997 1/1948 4/1943 24.3 % 0.25 [ 0.03, 2.23 ]
Mason 1993 1/1015 0/1001 16.2 % 2.96 [ 0.12, 72.54 ]
Subtotal (95% CI) 2963 2944 40.5 % 0.65 [ 0.06, 6.82 ]

Davies 1992 6/1246 1/1229 25.1 % 5.92 [ 0.71, 49.09 ]
Newnham 1993 3/1402 10/1399 34.4 % 0.30 [ 0.08, 1.09 ]
Subtotal (95% CI) 2648 2628 59.5 % 1.18 [ 0.06, 22.44 ]

Total (95% CI) 5611 5572 100.0 % 0.88 [ 0.17, 4.41 ]
Test for subgroup differences: Chi2 = 0.10, df = 1 (P = 0.75), I2 =0.0%
0.01 0.1 1 10 100


Potentially preventable perinatal death.
Outcome: 6 Potentially preventable perinatal death

M- M-
n/N n/N CI CI

French Doppler 1997 4/1949 12/1943 60.0 % 0.33 [ 0.11, 1.03 ]
Whittle 1994 3/1642 6/1344 40.0 % 0.41 [ 0.10, 1.63 ]
Subtotal (95% CI) 3591 3287 100.0 % 0.36 [ 0.15, 0.87 ]

Davies 1992 16/1246 4/1229 47.4 % 3.95 [ 1.32, 11.77 ]
Newnham 1993 10/1402 12/1399 52.6 % 0.83 [ 0.36, 1.92 ]
Subtotal (95% CI) 2648 2628 100.0 % 1.74 [ 0.37, 8.06 ]

0.01 0.1 1 10 100


Analysis 1.7. Comparison 1 All routine Doppler ultrasound versus no Doppler ultrasound, Outcome 7 Fetal
acidosis.
Outcome: 7 Fetal acidosis


French Doppler 1997 188/757 181/761 100.0 % 1.04 [ 0.87, 1.25 ]
Subtotal (95% CI) 757 761 100.0 % 1.04 [ 0.87, 1.25 ]

Total (95% CI) 757 761 100.0 % 1.04 [ 0.87, 1.25 ]
0.01 0.1 1 10 100


Apgar score < 7 at 5 minutes.
Outcome: 8 Apgar score < 7 at 5 minutes


Mason 1993 8/1015 12/1001 30.7 % 0.66 [ 0.27, 1.60 ]
Whittle 1994 11/1642 12/1344 33.6 % 0.75 [ 0.33, 1.69 ]
French Doppler 1997 8/1950 8/1948 20.4 % 1.00 [ 0.38, 2.66 ]
Subtotal (95% CI) 4607 4293 84.6 % 0.78 [ 0.47, 1.29 ]

Heterogeneity: Chi2 = 0.40, df = 2 (P = 0.82); I2 =0.0%
Davies 1992 9/1246 6/1229 15.4 % 1.48 [ 0.53, 4.14 ]
Subtotal (95% CI) 1246 1229 15.4 % 1.48 [ 0.53, 4.14 ]

Total (95% CI) 5853 5522 100.0 % 0.88 [ 0.56, 1.39 ]
0.01 0.1 1 10 100


Caesarean section (elective and emergency).
Outcome: 9 Caesarean section (elective and emergency)


French Doppler 1997 248/1950 251/1948 73.1 % 0.99 [ 0.84, 1.16 ]
Subtotal (95% CI) 1950 1948 73.1 % 0.99 [ 0.84, 1.16 ]

Davies 1992 91/1246 92/1229 26.9 % 0.98 [ 0.74, 1.29 ]
Subtotal (95% CI) 1246 1229 26.9 % 0.98 [ 0.74, 1.29 ]

Total (95% CI) 3196 3177 100.0 % 0.98 [ 0.85, 1.13 ]
0.01 0.1 1 10 100


Elective caesarean section.
Outcome: 10 Elective caesarean section


French Doppler 1997 134/1950 126/1948 40.1 % 1.06 [ 0.84, 1.34 ]
Mason 1993 29/1015 36/1001 11.5 % 0.79 [ 0.49, 1.29 ]
Whittle 1994 86/1642 64/1344 22.4 % 1.10 [ 0.80, 1.51 ]
Subtotal (95% CI) 4607 4293 74.0 % 1.03 [ 0.87, 1.23 ]

Davies 1992 78/1246 81/1229 26.0 % 0.95 [ 0.70, 1.28 ]
Subtotal (95% CI) 1246 1229 26.0 % 0.95 [ 0.70, 1.28 ]

Total (95% CI) 5853 5522 100.0 % 1.01 [ 0.87, 1.18 ]
0.01 0.1 1 10 100


Emergency caesarean section.
Outcome: 11 Emergency caesarean section


French Doppler 1997 114/1950 125/1948 91.9 % 0.91 [ 0.71, 1.17 ]
Subtotal (95% CI) 1950 1948 91.9 % 0.91 [ 0.71, 1.17 ]

Davies 1992 13/1246 11/1229 8.1 % 1.17 [ 0.52, 2.59 ]
Subtotal (95% CI) 1246 1229 8.1 % 1.17 [ 0.52, 2.59 ]

Total (95% CI) 3196 3177 100.0 % 0.93 [ 0.74, 1.18 ]
0.01 0.1 1 10 100


Spontaneous vaginal birth.
Outcome: 12 Spontaneous vaginal birth


French Doppler 1997 1373/1950 1397/1948 61.7 % 0.98 [ 0.94, 1.02 ]
Subtotal (95% CI) 1950 1948 61.7 % 0.98 [ 0.94, 1.02 ]

Davies 1992 877/1246 863/1229 38.3 % 1.00 [ 0.95, 1.06 ]
Subtotal (95% CI) 1246 1229 38.3 % 1.00 [ 0.95, 1.06 ]

Total (95% CI) 3196 3177 100.0 % 0.99 [ 0.96, 1.02 ]
0.01 0.1 1 10 100


Operative vaginal birth.
Outcome: 13 Operative vaginal birth


French Doppler 1997 329/1950 300/1948 34.0 % 1.10 [ 0.95, 1.26 ]
Whittle 1994 652/1642 530/1344 66.0 % 1.01 [ 0.92, 1.10 ]
Subtotal (95% CI) 3592 3292 100.0 % 1.04 [ 0.96, 1.12 ]

Total (95% CI) 3592 3292 100.0 % 1.04 [ 0.96, 1.12 ]
0.01 0.1 1 10 100


Induction of labour.
Outcome: 14 Induction of labour


French Doppler 1997 315/1950 275/1948 23.3 % 1.14 [ 0.99, 1.33 ]
Mason 1993 180/1015 177/1001 15.1 % 1.00 [ 0.83, 1.21 ]
Subtotal (95% CI) 2965 2949 38.4 % 1.09 [ 0.97, 1.22 ]

Heterogeneity: Chi2 = 1.16, df = 1 (P = 0.28); I2 =14%
Davies 1992 278/1246 274/1229 23.4 % 1.00 [ 0.86, 1.16 ]
Newnham 1993 459/1402 450/1399 38.2 % 1.02 [ 0.91, 1.13 ]
Subtotal (95% CI) 2648 2628 61.6 % 1.01 [ 0.93, 1.10 ]

Total (95% CI) 5613 5577 100.0 % 1.04 [ 0.97, 1.12 ]
0.5 0.7 1 1.5 2


Neonatal resuscitation.
Outcome: 15 Neonatal resuscitation


French Doppler 1997 133/1950 132/1948 70.8 % 1.01 [ 0.80, 1.27 ]
Subtotal (95% CI) 1950 1948 70.8 % 1.01 [ 0.80, 1.27 ]

Davies 1992 58/1246 54/1229 29.2 % 1.06 [ 0.74, 1.52 ]
Subtotal (95% CI) 1246 1229 29.2 % 1.06 [ 0.74, 1.52 ]

Total (95% CI) 3196 3177 100.0 % 1.02 [ 0.84, 1.24 ]
0.2 0.5 1 2 5

Infant intubation/ventilation.
Outcome: 16 Infant intubation/ventilation


Whittle 1994 23/1642 19/1344 100.0 % 0.99 [ 0.54, 1.81 ]
Subtotal (95% CI) 1642 1344 100.0 % 0.99 [ 0.54, 1.81 ]

Total (95% CI) 1642 1344 100.0 % 0.99 [ 0.54, 1.81 ]
0.01 0.1 1 10 100


Preterm birth (before 37 weeks).
Outcome: 17 Preterm birth (before 37 weeks)

M- M-
n/N n/N CI CI

French Doppler 1997 71/1950 59/1948 21.2 % 1.20 [ 0.86, 1.69 ]
Whittle 1994 74/1642 69/1344 23.4 % 0.88 [ 0.64, 1.21 ]
Subtotal (95% CI) 3592 3292 44.6 % 1.02 [ 0.75, 1.39 ]

Davies 1992 67/1248 53/1229 20.0 % 1.24 [ 0.88, 1.77 ]
Newnham 1993 113/1402 123/1399 35.5 % 0.92 [ 0.72, 1.17 ]
Subtotal (95% CI) 2650 2628 55.4 % 1.04 [ 0.77, 1.40 ]

Total (95% CI) 6242 5920 100.0 % 1.02 [ 0.86, 1.21 ]
0.5 0.7 1 1.5 2


Neonatal admission to SCBU/NICU.
Outcome: 18 Neonatal admission to SCBU/NICU


Mason 1993 29/1015 31/1001 12.4 % 0.92 [ 0.56, 1.52 ]
Whittle 1994 196/1642 161/1344 70.4 % 1.00 [ 0.82, 1.21 ]
Subtotal (95% CI) 2657 2345 82.8 % 0.99 [ 0.82, 1.18 ]

Davies 1992 44/1246 43/1229 17.2 % 1.01 [ 0.67, 1.53 ]
Subtotal (95% CI) 1246 1229 17.2 % 1.01 [ 0.67, 1.53 ]

Total (95% CI) 3903 3574 100.0 % 0.99 [ 0.84, 1.17 ]
0.5 0.7 1 1.5 2


Birthweight.
Outcome: 19 Birthweight
Mean Mean
Study or subgroup Doppler No Doppler Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

French Doppler 1997 1950 3271 (460) 1948 3285 (462) 72.7 % -14.00 [ -42.94, 14.94 ]
Mason 1993 1015 3258 (539) 1001 3285 (543) 27.3 % -27.00 [ -74.23, 20.23 ]
Subtotal (95% CI) 2965 2949 100.0 % -17.55 [ -42.23, 7.13 ]

Total (95% CI) 2965 2949 100.0 % -17.55 [ -42.23, 7.13 ]
-100 -50 0 50 100

Favours no Doppler Favours Doppler

Gestational age at birth.
Outcome: 20 Gestational age at birth
Mean Mean

French Doppler 1997 1950 39.3 (1.5) 1948 39.4 (1.4) 77.6 % -0.10 [ -0.19, -0.01 ]
Mason 1993 1015 39.38 (1.93) 1001 39.4 (1.95) 22.4 % -0.02 [ -0.19, 0.15 ]
Subtotal (95% CI) 2965 2949 100.0 % -0.08 [ -0.16, 0.00 ]

Total (95% CI) 2965 2949 100.0 % -0.08 [ -0.16, 0.00 ]
-100 -50 0 50 100


Analysis 2.1. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound, Outcome
1 Perinatal death (stillbirth and neonatal death including anomalies).
Comparison: 2 Single Doppler ultrasound assessment versus no Doppler ultrasound


French Doppler 1997 5/1948 14/1943 100.0 % 0.36 [ 0.13, 0.99 ]
Subtotal (95% CI) 1948 1943 100.0 % 0.36 [ 0.13, 0.99 ]

Total (95% CI) 1948 1943 100.0 % 0.36 [ 0.13, 0.99 ]
0.01 0.1 1 10 100


2 Stillbirth.


French Doppler 1997 2/1948 5/1943 100.0 % 0.40 [ 0.08, 2.05 ]
Subtotal (95% CI) 1948 1943 100.0 % 0.40 [ 0.08, 2.05 ]

Total (95% CI) 1948 1943 100.0 % 0.40 [ 0.08, 2.05 ]
0.01 0.1 1 10 100


3 Neonatal death (up to 28 days after birth).
Outcome: 3 Neonatal death (up to 28 days after birth)


French Doppler 1997 1/1948 4/1943 100.0 % 0.25 [ 0.03, 2.23 ]
Subtotal (95% CI) 1948 1943 100.0 % 0.25 [ 0.03, 2.23 ]

Total (95% CI) 1948 1943 100.0 % 0.25 [ 0.03, 2.23 ]
0.01 0.1 1 10 100


4 Any death after randomisation (non-prespecified).


French Doppler 1997 5/1948 14/1943 100.0 % 0.36 [ 0.13, 0.99 ]
Subtotal (95% CI) 1948 1943 100.0 % 0.36 [ 0.13, 0.99 ]

Total (95% CI) 1948 1943 100.0 % 0.36 [ 0.13, 0.99 ]
0.01 0.1 1 10 100


5 Potentially preventable perinatal death.


French Doppler 1997 4/1949 12/1943 100.0 % 0.33 [ 0.11, 1.03 ]
Subtotal (95% CI) 1949 1943 100.0 % 0.33 [ 0.11, 1.03 ]

Total (95% CI) 1949 1943 100.0 % 0.33 [ 0.11, 1.03 ]
0.01 0.1 1 10 100


6 Apgar score < 7 at 5 minutes.


French Doppler 1997 8/1950 8/1948 100.0 % 1.00 [ 0.38, 2.66 ]
Subtotal (95% CI) 1950 1948 100.0 % 1.00 [ 0.38, 2.66 ]

Total (95% CI) 1950 1948 100.0 % 1.00 [ 0.38, 2.66 ]
0.01 0.1 1 10 100


7 Caesarean section (elective and emergency).


French Doppler 1997 248/1950 251/1948 100.0 % 0.99 [ 0.84, 1.16 ]
Subtotal (95% CI) 1950 1948 100.0 % 0.99 [ 0.84, 1.16 ]

Total (95% CI) 1950 1948 100.0 % 0.99 [ 0.84, 1.16 ]
0.01 0.1 1 10 100


8 Elective caesarean section.


French Doppler 1997 134/1950 126/1948 100.0 % 1.06 [ 0.84, 1.34 ]
Subtotal (95% CI) 1950 1948 100.0 % 1.06 [ 0.84, 1.34 ]

Total (95% CI) 1950 1948 100.0 % 1.06 [ 0.84, 1.34 ]
0.01 0.1 1 10 100


9 Emergency caesarean section.


French Doppler 1997 114/1950 125/1948 100.0 % 0.91 [ 0.71, 1.17 ]
Subtotal (95% CI) 1950 1948 100.0 % 0.91 [ 0.71, 1.17 ]

Total (95% CI) 1950 1948 100.0 % 0.91 [ 0.71, 1.17 ]
0.01 0.1 1 10 100


Analysis 2.10. Comparison 2 Single Doppler ultrasound assessment versus no Doppler ultrasound,
Outcome 10 Spontaneous vaginal birth.


French Doppler 1997 1373/1950 1397/1948 100.0 % 0.98 [ 0.94, 1.02 ]
Subtotal (95% CI) 1950 1948 100.0 % 0.98 [ 0.94, 1.02 ]

Total (95% CI) 1950 1948 100.0 % 0.98 [ 0.94, 1.02 ]
0.01 0.1 1 10 100


Outcome 11 Operative vaginal birth.
Outcome: 11 Operative vaginal birth


French Doppler 1997 329/1950 300/1948 100.0 % 1.10 [ 0.95, 1.26 ]
Subtotal (95% CI) 1950 1948 100.0 % 1.10 [ 0.95, 1.26 ]

Total (95% CI) 1950 1948 100.0 % 1.10 [ 0.95, 1.26 ]
0.01 0.1 1 10 100


Outcome 12 Induction of labour.


French Doppler 1997 315/1950 275/1948 100.0 % 1.14 [ 0.99, 1.33 ]
Subtotal (95% CI) 1950 1948 100.0 % 1.14 [ 0.99, 1.33 ]

Total (95% CI) 1950 1948 100.0 % 1.14 [ 0.99, 1.33 ]
0.01 0.1 1 10 100


Outcome 13 Neonatal resuscitation.


French Doppler 1997 133/1950 132/1948 100.0 % 1.01 [ 0.80, 1.27 ]
Subtotal (95% CI) 1950 1948 100.0 % 1.01 [ 0.80, 1.27 ]

Total (95% CI) 1950 1948 100.0 % 1.01 [ 0.80, 1.27 ]
0.01 0.1 1 10 100


Outcome 14 Preterm birth (before 37 weeks).


French Doppler 1997 71/1950 59/1948 100.0 % 1.20 [ 0.86, 1.69 ]
Subtotal (95% CI) 1950 1948 100.0 % 1.20 [ 0.86, 1.69 ]

Total (95% CI) 1950 1948 100.0 % 1.20 [ 0.86, 1.69 ]
0.01 0.1 1 10 100


Outcome 15 Birthweight.
Mean Mean

French Doppler 1997 1950 3271 (460) 1948 3285 (462) 100.0 % -14.00 [ -42.94, 14.94 ]
Subtotal (95% CI) 1950 1948 100.0 % -14.00 [ -42.94, 14.94 ]

Total (95% CI) 1950 1948 100.0 % -14.00 [ -42.94, 14.94 ]
-100 -50 0 50 100


Outcome 16 Gestational age at birth.
Mean Mean

French Doppler 1997 1950 39.3 (1.5) 1948 39.4 (1.4) 100.0 % -0.10 [ -0.19, -0.01 ]
Subtotal (95% CI) 1950 1948 100.0 % -0.10 [ -0.19, -0.01 ]

Total (95% CI) 1950 1948 100.0 % -0.10 [ -0.19, -0.01 ]
-100 -50 0 50 100


Analysis 3.1. Comparison 3 Multiple Doppler ultrasound assessments versus no Doppler ultrasound,
Outcome 1 Perinatal death (stillbirth and neonatal death including anomalies).
Comparison: 3 Multiple Doppler ultrasound assessments versus no Doppler ultrasound

M- M-
n/N n/N CI CI
Mason 1993 4/1015 5/1001 25.4 % 0.79 [ 0.21, 2.93 ]
Subtotal (95% CI) 1015 1001 25.4 % 0.79 [ 0.21, 2.93 ]

Davies 1992 17/1246 7/1229 34.9 % 2.40 [ 1.00, 5.76 ]
Newnham 1993 13/1402 22/1399 39.7 % 0.59 [ 0.30, 1.17 ]
Subtotal (95% CI) 2648 2628 74.6 % 1.16 [ 0.29, 4.56 ]

Total (95% CI) 3663 3629 100.0 % 1.04 [ 0.40, 2.66 ]
0.01 0.1 1 10 100


Outcome 2 Serious neonatal morbidity.
Outcome: 2 Serious neonatal morbidity


Mason 1993 1/1015 1/1001 100.0 % 0.99 [ 0.06, 15.75 ]
Subtotal (95% CI) 1015 1001 100.0 % 0.99 [ 0.06, 15.75 ]

Total (95% CI) 1015 1001 100.0 % 0.99 [ 0.06, 15.75 ]
0.01 0.1 1 10 100


Outcome 3 Any death after randomisation (non-prespecified).

M- M-
n/N n/N CI CI

Mason 1993 4/1015 5/1001 15.7 % 0.79 [ 0.21, 2.93 ]
Subtotal (95% CI) 1015 1001 15.7 % 0.79 [ 0.21, 2.93 ]

Davies 1992 22/1246 13/1229 36.0 % 1.67 [ 0.84, 3.30 ]
Newnham 1993 30/1402 41/1399 48.3 % 0.73 [ 0.46, 1.16 ]
Subtotal (95% CI) 2648 2628 84.3 % 1.06 [ 0.47, 2.38 ]

Total (95% CI) 3663 3629 100.0 % 1.00 [ 0.55, 1.80 ]
0.01 0.1 1 10 100


Outcome 4 Stillbirth.

M- M-
n/N n/N CI CI

Davies 1992 11/1246 4/1229 44.4 % 2.71 [ 0.87, 8.50 ]
Newnham 1993 10/1402 12/1399 55.6 % 0.83 [ 0.36, 1.92 ]
Subtotal (95% CI) 2648 2628 100.0 % 1.41 [ 0.44, 4.46 ]

Total (95% CI) 2648 2628 100.0 % 1.41 [ 0.44, 4.46 ]
0.01 0.1 1 10 100


Outcome 5 Neonatal death (up to 28 days).
Outcome: 5 Neonatal death (up to 28 days)

M- M-
n/N n/N CI CI

Mason 1993 1/1015 0/1001 23.9 % 2.96 [ 0.12, 72.54 ]
Subtotal (95% CI) 1015 1001 23.9 % 2.96 [ 0.12, 72.54 ]

Davies 1992 6/1246 1/1229 33.8 % 5.92 [ 0.71, 49.09 ]
Newnham 1993 3/1402 10/1399 42.4 % 0.30 [ 0.08, 1.09 ]
Subtotal (95% CI) 2648 2628 76.1 % 1.18 [ 0.06, 22.44 ]

Total (95% CI) 3663 3629 100.0 % 1.42 [ 0.16, 12.36 ]
0.01 0.1 1 10 100


Outcome 6 Potentially preventable perinatal death.


Davies 1992 16/1246 4/1229 25.1 % 3.95 [ 1.32, 11.77 ]
Newnham 1993 10/1402 12/1399 74.9 % 0.83 [ 0.36, 1.92 ]
Subtotal (95% CI) 2648 2628 100.0 % 1.61 [ 0.87, 3.00 ]

Total (95% CI) 2648 2628 100.0 % 1.61 [ 0.87, 3.00 ]
0.01 0.1 1 10 100


Outcome 7 Apgar score < 7 at 5 minutes.


Mason 1993 8/1015 12/1001 66.7 % 0.66 [ 0.27, 1.60 ]
Subtotal (95% CI) 1015 1001 66.7 % 0.66 [ 0.27, 1.60 ]

Davies 1992 9/1246 6/1229 33.3 % 1.48 [ 0.53, 4.14 ]
Subtotal (95% CI) 1246 1229 33.3 % 1.48 [ 0.53, 4.14 ]

Total (95% CI) 2261 2230 100.0 % 0.93 [ 0.48, 1.80 ]
0.01 0.1 1 10 100


Outcome 8 Caesarean section (elective and emergency).


Davies 1992 91/1246 92/1229 100.0 % 0.98 [ 0.74, 1.29 ]
Subtotal (95% CI) 1246 1229 100.0 % 0.98 [ 0.74, 1.29 ]

Total (95% CI) 1246 1229 100.0 % 0.98 [ 0.74, 1.29 ]
0.01 0.1 1 10 100


Outcome 9 Elective caesarean section.


Mason 1993 29/1015 36/1001 30.8 % 0.79 [ 0.49, 1.29 ]
Subtotal (95% CI) 1015 1001 30.8 % 0.79 [ 0.49, 1.29 ]

Davies 1992 78/1246 81/1229 69.2 % 0.95 [ 0.70, 1.28 ]
Subtotal (95% CI) 1246 1229 69.2 % 0.95 [ 0.70, 1.28 ]

Total (95% CI) 2261 2230 100.0 % 0.90 [ 0.70, 1.16 ]
0.01 0.1 1 10 100


Outcome 10 Emergency caesarean section.


Davies 1992 13/1246 11/1229 100.0 % 1.17 [ 0.52, 2.59 ]
Subtotal (95% CI) 1246 1229 100.0 % 1.17 [ 0.52, 2.59 ]

Total (95% CI) 1246 1229 100.0 % 1.17 [ 0.52, 2.59 ]
0.01 0.1 1 10 100


Outcome 11 Spontaneous vaginal birth.


Davies 1992 877/1246 863/1229 100.0 % 1.00 [ 0.95, 1.06 ]
Subtotal (95% CI) 1246 1229 100.0 % 1.00 [ 0.95, 1.06 ]

Total (95% CI) 1246 1229 100.0 % 1.00 [ 0.95, 1.06 ]
0.01 0.1 1 10 100


Outcome 12 Induction of labour.


Mason 1993 180/1015 177/1001 19.7 % 1.00 [ 0.83, 1.21 ]
Subtotal (95% CI) 1015 1001 19.7 % 1.00 [ 0.83, 1.21 ]

Davies 1992 278/1246 274/1229 30.5 % 1.00 [ 0.86, 1.16 ]
Newnham 1993 459/1402 450/1399 49.8 % 1.02 [ 0.91, 1.13 ]
Subtotal (95% CI) 2648 2628 80.3 % 1.01 [ 0.93, 1.10 ]

Total (95% CI) 3663 3629 100.0 % 1.01 [ 0.93, 1.09 ]
0.5 0.7 1 1.5 2


Outcome 13 Neonatal resuscitation.


Davies 1992 58/1246 54/1229 100.0 % 1.06 [ 0.74, 1.52 ]
Subtotal (95% CI) 1246 1229 100.0 % 1.06 [ 0.74, 1.52 ]

Total (95% CI) 1246 1229 100.0 % 1.06 [ 0.74, 1.52 ]
0.01 0.1 1 10 100


Outcome 14 Preterm birth (before 37 weeks).


Whittle 1994 74/1642 69/1344 30.1 % 0.88 [ 0.64, 1.21 ]
Subtotal (95% CI) 1642 1344 30.1 % 0.88 [ 0.64, 1.21 ]

Davies 1992 67/1248 53/1229 21.2 % 1.24 [ 0.88, 1.77 ]
Newnham 1993 113/1402 123/1399 48.8 % 0.92 [ 0.72, 1.17 ]
Subtotal (95% CI) 2650 2628 69.9 % 1.02 [ 0.83, 1.24 ]

Total (95% CI) 4292 3972 100.0 % 0.97 [ 0.82, 1.15 ]
0.01 0.1 1 10 100


Outcome 15 Neonatal admission to SCBU/NICU.
Outcome: 15 Neonatal admission to SCBU/NICU


Mason 1993 29/1015 31/1001 41.9 % 0.92 [ 0.56, 1.52 ]
Subtotal (95% CI) 1015 1001 41.9 % 0.92 [ 0.56, 1.52 ]

Davies 1992 44/1246 43/1229 58.1 % 1.01 [ 0.67, 1.53 ]
Subtotal (95% CI) 1246 1229 58.1 % 1.01 [ 0.67, 1.53 ]

Total (95% CI) 2261 2230 100.0 % 0.97 [ 0.71, 1.34 ]
0.01 0.1 1 10 100


Outcome 16 Birthweight.
Mean Mean

Mason 1993 1015 3258 (539) 1001 3285 (543) 100.0 % -27.00 [ -74.23, 20.23 ]
Subtotal (95% CI) 1015 1001 100.0 % -27.00 [ -74.23, 20.23 ]

Total (95% CI) 1015 1001 100.0 % -27.00 [ -74.23, 20.23 ]
-100 -50 0 50 100


Outcome 17 Gestational age at birth.
Mean Mean

Mason 1993 1015 39.38 (1.93) 1001 39.4 (1.95) 100.0 % -0.02 [ -0.19, 0.15 ]
Subtotal (95% CI) 1015 1001 100.0 % -0.02 [ -0.19, 0.15 ]

Total (95% CI) 1015 1001 100.0 % -0.02 [ -0.19, 0.15 ]
-100 -50 0 50 100

WHAT’S NEW
Last assessed as up-to-date: 28 February 2015.
Date Event Description
11 June 2015 Amended Added Acknowledgements statement.

HISTORY
Protocol first published: Issue 2, 1999
Review first published: Issue 2, 2000
Date Event Description
27 March 2015 New citation required but conclusions have not Review updated.
changed
27 March 2015 New search has been performed Search updated on 28 February 2015 and two reports
identified (Forward 2014; Stoch 2012). Both studies
were added to references as additional follow-up data
for Newnham 1993.
Background and Methods have been updated and
a ’Summary of findings’ table incorporated - see
Differences between protocol and review for details.
28 January 2010 New citation required but conclusions have not New review team substantially updated the review.
changed
20 May 2009 New search has been performed Search updated. Six new trials excluded (Ellwood 1997;
Goffinet 2001; Scholler 1993; Snaith 2006; Subtil
2000; Subtil 2003).
6 November 2008 Amended Converted to new review format.
5 February 2007 Amended Review withdrawn from publication.
14 January 2000 New citation required and conclusions have changed Substantive amendment
CONTRIBUTIONS OF AUTHORS
Following discussions with Z Alfirevic (ZA), T Stampalija (TS) re-wrote the protocol section and G Gyte (GG) updated the methods
section. TS and GG selected studies and extracted the data. TS entered the data into RevMan 2008 and GG checked the data entry.
ZA drew the evidence together in the discussion and recommendations and made further comments.
For the 2015 update, following discussions with Z Alfirevic, T Stampalija and N Medley updated the data analysis and text of the
review.

DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
• The University of Liverpool, UK.
External sources
• National Institute for Health Research, UK.
NIHR NHS Cochrane Collaboration Programme Grant Scheme award for NHS-prioritised centrally-managed, pregnancy and
childbirth systematic reviews: CPGS02
• UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human
Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization, Switzerland.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

We updated the Background and Methods sections to reflect the Cochrane Handbook for Systematic Reviews of Interventions (Higgins
2011) and changed the title from ’Routine Doppler ultrasound in normal pregnancy’ to ’Fetal and umbilical Doppler ultrasound in normal
pregnancy’.
We changed the outcome of ’Preterm labour (onset of labour before 37 weeks)’ to ’Preterm birth (birth less than 37 weeks)’ because
this was the outcome reported in the studies.
We have clarified the primary outcome from ’Any perinatal death after randomisation’ to ’Perinatal deaths (stillbirths and neonatal
deaths including anomalies)’ and added ’Any death after randomisation’ (all losses or deaths after randomisation, including miscarriage)
as a new outcome for this update.
We have added data from Newnham 1993 and recalculated the outcome of potentially preventable perinatal death (Analysis 1.6), so
this analysis differs from the outcome of the same name in the previously published version of the review (Analysis 1.5). We decided
not to pool the subgroups in this update, but the substantive conclusions from subgroups have not changed.
The methods have been updated to reflect the current standard template used by the Cochrane Pregnancy and Childbirth Group. A
’Summary of findings’ table has been incorporated.
INDEX TERMS
Medical Subject Headings (MeSH)

∗ Ultrasonography, Doppler; Perinatal Mortality; Pregnancy Outcome; Randomized Controlled Trials as Topic; Ultrasonography, Pre-
natal [∗ methods]; Umbilical Arteries [∗ diagnostic imaging]; Uterine Artery [diagnostic imaging]

MeSH check words
Female; Humans; Infant, Newborn; Pregnancy


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Cochrane Database of Systematic Reviews

Fetal and umbilical Doppler ultrasound in normal pregnancy

Alfirevic Z, Stampalija T, Medley N

Alfirevic Z, Stampalija T, Medley N.

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review)

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) iii

Fetal and umbilical Doppler ultrasound in normal pregnancy

Zarko Alfirevic1 , Tamara Stampalija2 , Nancy Medley3

Editorial group: Cochrane Pregnancy and Childbirth Group.

PLAIN LANGUAGE SUMMARY

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 2

All routine Doppler ultrasound versus no Doppler ultrasound

Patient or population: Pregnant wom en in unselected or low-risk populations.

Assumed risk Corresponding risk

No Doppler ultrasound All routine Doppler ul-

Perinatal death (still- Study population RR 0.8 11183 ⊕⊕

7 per 1000 6 per 1000

Serious neonatal mor- Study population RR 0.99 2016 ⊕⊕

1 per 1000 1 per 1000

4 per 1000 1 per 1000

Stillbirth - Fetal/ umbil- Study population RR 1.41 5276 ⊕⊕

6 per 1000 8 per 1000

Cae- Study population RR 0.98 6373 ⊕⊕⊕⊕

102 per 1000 100 per 1000

Preterm birth (before Study population RR 1.02 12162 ⊕⊕⊕⊕

47 per 1000 48 per 1000

Neonatal admission to Study population RR 0.99 7477 ⊕⊕⊕

35 per 1000 35 per 1000

GRADE Working Group grades of evidence

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 6

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 7

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 8

(3.2) Blinding of outcome assessment (checking for possible

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 9

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 10

Results of the search

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 11

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 12

Selective reporting 2. Serious neonatal morbidity

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 13

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 14

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 15

Overall completeness and applicability of Agreements and disagreements with other

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 16

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 19

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 20

Characteristics of included studies [ordered by study ID]

Participants Inclusion criteria

Interventions Experimental intervention: Doppler ultrasound of umbilical-artery and uterine-artery

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 21

Bias Authors’ judgement Support for judgement

Blinding of participants and personnel High risk Blinding not possible.

Blinding of outcome assessment (detection High risk Blinding not possible.

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 22

Describe any baseline imbalance:

French Doppler 1997

Methods Multicentre randomised controlled trial. Individual women. Randomisation in blocks

Participants Inclusion criteria

Interventions Experimental intervention: umbilical Doppler ultrasound

Outcomes • AN consultations; days of AN hospitalisation; CTG; ultrasound and Doppler

Fetal and umbilical Doppler ultrasound in normal pregnancy (Review) 23

Bias Authors’ judgement Support for judgement

Blinding of participants and personnel High risk Blinding not possible.